{ "hospital_name": "Huntington Beach Hospital", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "Huntington Beach Hospital" ], "hospital_address": [ "17772 Beach Boulevard Huntington Beach, CA 92647" ], "license_information": { "license_number": "205252882", "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": "Dan Brothman" }, "type_2_npi": [ "1083622120", "1780986356" ], "standard_charge_information": [ { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5515, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10855.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4247.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7148.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 4", "code_information": [ { "code": "5434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17669.85, "maximum": 18906.74, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18906.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": 9940, "minimum": 7733.3164, "maximum": 18011.6062, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9940.18, "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": 10039.58, "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": 15826.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11455.89 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12922.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18011.61, "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": 14512.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13975.89, "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": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10536.59, "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": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15904.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10049.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9940.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15826.14 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3128.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6393.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8458, "minimum": 5400.47, "maximum": 28999.6412, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8458.56, "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": 8543.15, "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": 13749.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14188.26 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10996.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15326.91, "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": 12349.5, "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": 11892.74, "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": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8966.07, "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": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13533.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5400.47 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8458.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13749.32 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15397.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4007.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6851.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 & 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10507.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 & 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20067.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14124.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16404, "minimum": 9066.71, "maximum": 29725.1533, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16404.61, "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": 16568.65, "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": 23190.58 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21194.9 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21325.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16404.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29725.15, "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": 23950.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 23064.88, "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": 16404.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17388.88, "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": 16404.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16404.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16404.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26247.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16404.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16404.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9066.71 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16404.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23190.58 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8710.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9270, "minimum": 9270.05, "maximum": 16797.3306, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14832.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12794.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14399.43 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9270.05, "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": 9362.75, "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": 14399.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15563.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12051.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16797.33, "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": 13534.27, "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": 13033.69, "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": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9826.25, "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": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9270.05, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25578, "minimum": 20161.9028, "maximum": 46347.3541, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25578.01, "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": 25833.78, "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": 40175.73 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37191.84 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 33251.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 25578.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46347.35, "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": 37343.89, "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": 35962.68, "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": 25578, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27112.68, "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": 25578, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25578.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25578, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40924.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 25578, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25578.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35202.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25578, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40175.73 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4125.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9550, "minimum": 5936, "maximum": 17304.6725, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9550.04, "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": 9645.54, "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": 14099.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13691.99 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12415.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17304.67, "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": 13943.06, "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": 13427.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10123.04, "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": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15280.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7733.96 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9550.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14099.38 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9195.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5317.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7257.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3565.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7949, "minimum": 3645.05, "maximum": 14403.733, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7949.08, "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": 8028.57, "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": 9976.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10678.49 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10333.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14403.73, "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": 11605.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11176.41, "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": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8426.02, "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": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12718.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3645.05 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7949.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9976.64 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11743.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9508.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7521.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7104.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4294.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18265.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5214.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10157.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16276.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11684.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16196.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48234.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 LEUKEMIA - SOI : 3", "code_information": [ { "code": "6903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25746.65, "maximum": 27548.92, "payers_information": [ { "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" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27548.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "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": 11930, "minimum": 10800, "maximum": 56748.3916, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11930.37, "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": 12049.7, "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": 18689.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20251.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15509.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11930.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21617.83, "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": 17418.34, "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": 16774.1, "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": 11930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12646.22, "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": 11930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11930.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19088.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11930.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16606.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11930.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18689.84 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9172, "minimum": 8541.2572, "maximum": 16621.023, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9172.75, "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": 9264.48, "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": 13558.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.31 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16621.02, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13392.22, "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": 12896.89, "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": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9723.12, "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": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14676.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12091.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9172.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13558.11 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15460, "minimum": 10856.4092, "maximum": 28015.2052, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15460.93, "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": 15615.51, "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": 24142.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22755.44 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20099.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15460.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28015.21, "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": 22572.96, "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": 21738.07, "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": 15460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16388.55, "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": 15460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15460.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24737.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15460.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17935.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15460.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24142.21 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19882, "minimum": 14404.734, "maximum": 36027.7242, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19882.85, "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": 20081.63, "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": 31415.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32064.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25847.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19882.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36027.72, "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": 29028.96, "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": 27955.29, "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": 19882.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21075.77, "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": 19882.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19882.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19882.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31812.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19882.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19882.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23758.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19882.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31415.47 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6233, "minimum": 5850, "maximum": 26137.5936, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6233.37, "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": 6295.7, "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": 8257.24 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7009.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8103.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11294.87, "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": 9100.72, "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": 8764.12, "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": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6607.37, "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": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9973.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7337.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6233.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8257.24 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51131, "minimum": 24637.4696, "maximum": 107216, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 51131.89, "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": 51643.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 81297.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80307.4 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 66471.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 51131.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 92650.98, "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": 74652.56, "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": 71891.44, "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": 51131.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54199.81, "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": 51131.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51131.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51131.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 81811.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 51131.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51131.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 107216 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 51131.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81297.21 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7373, "minimum": 7373.5, "maximum": 23397.2096, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7373.5, "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": 7447.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10664.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10299.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9585.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13360.78, "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": 10765.31, "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": 10367.14, "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": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7815.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 7650, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 18000, "10th_percentile": 18000, "90th_percentile": 18000, "count": "1 through 10" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11797.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10845.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7373.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10664.99 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2333.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11414, "minimum": 5684.21, "maximum": 20683.0015, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11414.46, "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": 11528.65, "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": 17108.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18376.47 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14838.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11414.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20683, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16665.11, "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": 16048.73, "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": 11414.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12099.37, "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": 11414.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11414.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11414.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18263.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11414.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11414.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5684.21 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11414.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17108.7 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7089, "minimum": 7074.2068, "maximum": 12846.7901, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7089.84, "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": 7160.74, "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": 10898.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10609.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9216.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12846.79, "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": 10351.17, "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": 9968.32, "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": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7515.23, "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": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11343.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9683.64 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10898.85 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3142.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9243.46, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18918, "minimum": 8176.2664, "maximum": 34281.1736, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18918.97, "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": 19108.19, "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": 28760.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28276.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24594.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18918.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34281.17, "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": 27621.7, "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": 26600.07, "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": 18919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20054.14, "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": 18919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18918.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30270.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18918.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33291.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18919, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28760.62 } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11656, "minimum": 7414.3924, "maximum": 29042.7, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11656.81, "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": 11773.37, "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": 15870.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15387.35 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15153.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11656.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21122.14, "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": 17018.94, "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": 16389.47, "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": 11656.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12356.21, "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": 11656.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11656.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11656.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18650.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11656.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11656.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29042.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11656.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15870.26 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13580, "minimum": 6750, "maximum": 41193.1688, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13580.9, "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": 13716.71, "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": 21077 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21100.24 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17655.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24608.59, "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": 19828.11, "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": 19094.75, "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": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14395.75, "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": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21729.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19410.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13580.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21077 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25772.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5823.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17855, "minimum": 13301.4932, "maximum": 32353.2962, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17855.02, "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": 18033.55, "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": 27303.02 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26542.03 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23211.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17855.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32353.3, "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": 26068.33, "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": 25104.16, "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": 17855, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18926.3, "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": 17855, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17855.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17855, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28568.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17855, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17855.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24259.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17855, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27303.02 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48465.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20855, "minimum": 12150, "maximum": 37790.9089, "payers_information": [ { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33369.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20855.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20855.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32008.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20855.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33520.22 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20855.91, "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": 21064.46, "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": 33520.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32306.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 27112.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20855.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37790.91, "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": 30449.63, "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": 29323.41, "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": 20855.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22107.25, "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": 20855.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20855.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20855.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33950, "minimum": 18450, "maximum": 72388.6608, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33950.01, "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": 34289.5, "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": 52467.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50690.19 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 44135, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 33950.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 61517.42, "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": 49567.01, "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": 47733.71, "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": 33950, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35987, "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": 33950, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33950.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33950, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54320.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 33950, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33950.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46618 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33950, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52467.46 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13991.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6497, "minimum": 6497.75, "maximum": 23186.6, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6497.75, "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": 6562.73, "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": 8620.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9159.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8447.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11773.92, "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": 9486.72, "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": 9135.84, "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": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.62, "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": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10396.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23186.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6497.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8620.54 } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42617, "minimum": 19350, "maximum": 77223.0912, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 42617.6, "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": 43043.78, "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": 71876.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64994.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 55402.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 77223.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 62221.7, "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": 59920.35, "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": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45174.66, "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": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 68188.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63862.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 42617.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71876.54 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4126.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11072, "minimum": 9495.6668, "maximum": 20064.2216, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11072.97, "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": 11183.73, "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": 16748.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16237.9 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14394.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11072.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20064.22, "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": 16166.54, "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": 15568.6, "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": 11073, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11737.38, "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": 11073, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11072.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11073, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17716.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11073, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11072.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18363 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11073, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16748.35 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20273.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20654.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": 8115, "minimum": 8115.23, "maximum": 16829.7376, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8115.23, "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": 8196.38, "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": 12025.51 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11190.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10549.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14704.8, "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": 11848.24, "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": 11410.01, "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": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8602.14, "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": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12984.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11762.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8115.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12025.51 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8887.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3518.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13730, "minimum": 8665.24, "maximum": 34200, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13730.53, "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": 13867.81, "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": 21296.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23075.29 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17849.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13730.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24879.72, "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": 20046.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 19305.13, "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": 13730.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14554.33, "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": 13730.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13730.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13730.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21968.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13730.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13730.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8665.24 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13730.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21296.15 } ] } ] }, { "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": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4850.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16755, "minimum": 10176, "maximum": 30360.5674, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16755.28, "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": 16922.85, "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": 26192.55 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25503.59 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21781.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16755.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30360.57, "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": 24462.71, "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": 23557.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17760.62, "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": 16755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16755.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26808.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16755.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13802 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26192.55 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5078.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3027.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7341.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8839, "minimum": 6996, "maximum": 16017.2102, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8927.92, "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": 12975.67 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12272.02 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11491.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16017.21, "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": 12905.7, "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": 12428.37, "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": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9369.89, "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": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14143.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8839.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12975.67 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6864.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4368.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6398, "minimum": 4452, "maximum": 11594.2632, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6398.6, "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": 6462.59, "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": 9179.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8240.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8318.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11594.26, "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": 9341.96, "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": 8996.43, "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": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6782.52, "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": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10237.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4542.19 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6398.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9179.45 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16223.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16172, "minimum": 7870.3356, "maximum": 29304.3163, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16172.36, "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": 16334.12, "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": 25561.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25444.78 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21024.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16172.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29304.32, "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": 23611.65, "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": 22738.34, "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": 16172.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17142.74, "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": 16172.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16172.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16172.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25875.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16172.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16172.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18128.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16172.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25561.56 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5223.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10436.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6852, "minimum": 5200.33, "maximum": 18525.9408, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6852.09, "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": 6920.61, "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": 9767.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9449.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8907.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12415.99, "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": 10004.05, "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": 9634.04, "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": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7263.22, "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": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10963.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5200.33 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6852.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9767.78 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 95522.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20585.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": 111057, "minimum": 111057.78, "maximum": 201236.6974, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 156147.24, "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": 111058, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 117721.48, "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": 111058, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 111057.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 111058, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 177692.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 111058, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 111057.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 138282 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 111058, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 192705.26 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 111057.78, "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": 112168.58, "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": 192705.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 164385.62 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 144375.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 111057.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 201236.7, "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": 162144.36, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 1", "code_information": [ { "code": "0071", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55309.66, "maximum": 59181.34, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59181.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8585.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71097.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 160324.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9738.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5234.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6939.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 13444, "minimum": 13444.1, "maximum": 37713.3536, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13444.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13578.54, "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": 22208.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19994.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17477.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13444.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24360.75, "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": 19628.42, "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": 18902.43, "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": 13444.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14250.75, "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": 13444.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13444.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13444.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21510.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13444.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13444.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19732.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13444.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22208.07 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16330.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19795.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13777.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21626, "minimum": 21626.1, "maximum": 39186.4932, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21842.36, "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": 31730.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30761.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 28113.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39186.49, "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": 31574.11, "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": 30406.3, "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": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22923.67, "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": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34601.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24617 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21626.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31730.22 } ] } ] }, { "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": 45915, "minimum": 33670.106, "maximum": 83199.6289, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 45915.91, "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": 46375.06, "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": 74084.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68944.74 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 59690.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 45915.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83199.63, "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": 67037.23, "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": 64557.77, "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": 45915.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 48670.85, "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": 45915.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45915.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45915.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 73465.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 45915.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45915.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46592.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45915.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74084.26 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6695.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "476", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11569, "minimum": 10129.9, "maximum": 20964.1152, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11569.6, "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": 11685.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17107.23 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16880.48 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15040.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20964.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16891.62, "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": 16266.86, "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": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12263.78, "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": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18511.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10129.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11569.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17107.23 } ] } ] }, { "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": 26902, "minimum": 16352.5328, "maximum": 48747.6199, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 26902.66, "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": 27171.73, "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": 42833.52 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40292.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34973.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 26902.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 48747.62, "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": 39277.88, "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": 37825.14, "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": 26902.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28516.86, "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": 26902.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26902.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26902.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43044.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 26902.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26902.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24535.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 26902.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42833.52 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10065.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9165.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40143, "minimum": 40143.6, "maximum": 72740.2757, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 40143.64, "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": 40545.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 65962.33 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61715.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 52186.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 40143.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 72740.28, "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": 58609.71, "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": 56441.96, "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": 40143.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42552.22, "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": 40143.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40143.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40143.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64229.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 40143.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40143.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 67913.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40143.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65962.33 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33405.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3150, "minimum": 146.17, "maximum": 3150, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] }, { "setting": "outpatient", "gross_charge": 3150, "minimum": 146.17, "maximum": 3150, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 156.4 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13461.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 17904, "minimum": 16752.9596, "maximum": 32443.1352, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17904.6, "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": 18083.65, "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": 28410.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28464.02 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23275.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32443.14, "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": 26140.72, "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": 25173.87, "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": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18978.88, "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": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28647.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17896.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17904.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28410.56 } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 39503, "minimum": 6750, "maximum": 71580.8856, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 39503.8, "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": 39898.84, "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": 61196.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59647.5 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 51354.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 71580.89, "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": 57675.55, "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": 55542.34, "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": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41874.03, "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": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 63206.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8075.39 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 39503.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61196.84 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4263.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 32749, "minimum": 22091.9836, "maximum": 59341.7135, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 32749.29, "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": 33076.79, "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": 56847.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56765.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 42574.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 32749.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59341.71, "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": 47813.96, "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": 46045.5, "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": 32749.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34714.26, "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": 32749.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32749.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32749.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52398.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 32749.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32749.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28907.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 32749.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56847.6 } ] } ] }, { "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": 13755, "minimum": 13755.3, "maximum": 34105.9688, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13755.32, "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": 13892.85, "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": 18313.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16659.59 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17881.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13755.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24924.64, "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": 20082.77, "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": 19339.98, "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": 13755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14580.62, "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": 13755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13755.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22008.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13755.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16272 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13755.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18313.31 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25805.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11657.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8792.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23223.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7852.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8727, "minimum": 7650, "maximum": 18007.394, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8727.53, "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": 8814.81, "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": 12956.55 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13996.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11345.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15814.28, "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": 12742.19, "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": 12270.91, "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": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9251.18, "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": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13964.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8688.78 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8727.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12956.55 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12750, "minimum": 12750.1, "maximum": 29434.3228, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12750.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.6, "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": 18516.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18666.2 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16575.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12750.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23103.22, "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": 18615.18, "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": 17926.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12750.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13515.11, "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": 12750.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12750.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12750.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20400.19, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12750.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12750.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15821.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12750.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18516.28 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14144.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ANES ADDL 15 MIN", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "minimum": 58.47, "maximum": 10500, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.56 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] }, { "setting": "outpatient", "gross_charge": 10500, "minimum": 58.47, "maximum": 10500, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.56 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21808, "minimum": 10283.5272, "maximum": 39517.5094, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21808.78, "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": 22026.89, "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": 34811.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36562.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 28351.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21808.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39517.51, "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": 31840.82, "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": 30663.14, "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": 21808.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23117.33, "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": 21808.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21808.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21808.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34894.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21808.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21808.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30930 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21808.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34811.61 } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18000, "maximum": 35678.146, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25838.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19594.2 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22957 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25838.08 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2426.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17721.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7178, "minimum": 7178.89, "maximum": 24630.3824, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7178.89, "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": 7250.68, "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": 10270.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10012.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9332.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13008.15, "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": 10481.18, "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": 10093.52, "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": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7609.62, "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": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11486.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7772.82 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10270.81 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7139.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9338.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4665.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5172.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6915, "minimum": 6133.96, "maximum": 18613.3496, "payers_information": [ { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9889.86 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6915.43, "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": 6984.58, "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": 9889.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9439.24 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8990.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12530.76, "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": 10096.53, "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": 9723.09, "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": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7330.36, "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": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11064.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6915.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6133.96 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17117.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14182.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4521.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9643.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63873, "minimum": 17764.9, "maximum": 115738.7458, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 63873.48, "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": 64512.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 98069.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98318.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 83035.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 63873.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 115738.75, "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": 93255.28, "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": 89806.11, "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": 63873.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 67705.91, "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": 63873.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63873.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63873.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 102197.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 63873.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63873.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17764.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 63873.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98069.09 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69665.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14329.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12031.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27433.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7560.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3476.19, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5142.94, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14630, "minimum": 13500, "maximum": 30791, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14630.15, "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": 14776.5, "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": 22256.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21705.52 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19019.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14630.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26509.83, "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": 21360.02, "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": 20569.99, "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": 14630.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15508.01, "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": 14630.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14630.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14630.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23408.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14630.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14630.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30791 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14630.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22256.61 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23121.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8895.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31216.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11243, "minimum": 8550, "maximum": 20373.6206, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11243.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11356.14, "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": 16529.19 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15965.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14616.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11243.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20373.62, "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": 16415.83, "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": 15808.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11243.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11918.32, "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": 11243.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11243.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11243.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17989.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11243.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11243.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19805.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11243.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16529.19 } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22720, "minimum": 22720.3, "maximum": 41169.238, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22720.33, "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": 22947.5, "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": 36444.24 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32223.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 29536.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 22720.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41169.24, "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": 33171.68, "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": 31944.78, "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": 22720.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24083.52, "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": 22720.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22720.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22720.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36352.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22720.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22720.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34243 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22720.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36444.24 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27517.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 50603, "minimum": 50603.1, "maximum": 91692.8716, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 50603.13, "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": 51109.13, "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": 88777.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88597.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 65784.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 50603.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 91692.87, "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": 73880.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 71148, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50603.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53639.29, "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": 50603.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 50603.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50603.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 80965.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 50603.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 50603.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 78879.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 50603.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88777.85 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24412, "minimum": 24412.17, "maximum": 44234.852, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 24412.17, "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": 24656.32, "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": 35258.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34196.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31735.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44234.85, "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": 35641.77, "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": 34323.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25876.93, "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": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39059.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29988.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35258.75 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24412, "minimum": 16092.6688, "maximum": 44234.852, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 24412.17, "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": 24656.32, "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": 35258.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31263.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31735.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44234.85, "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": 35641.77, "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": 34323.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25876.93, "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": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39059.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22931.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35258.75 } ] } ] }, { "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": 35043, "minimum": 23626.3624, "maximum": 63498.514, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 35043.33, "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": 35393.73, "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": 52714.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52378.38 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 45556.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 35043.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63498.51, "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": 51163.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 49270.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35043.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37145.9, "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": 35043.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35043.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35043.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56069.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 35043.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35043.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38797 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 35043.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52714.56 } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11720, "minimum": 8919.2412, "maximum": 21236.9118, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11720.15, "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": 11837.4, "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": 17110.17 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16080.13 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15236.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11720.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21236.91, "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": 17111.42, "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": 16478.53, "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": 11720.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12423.41, "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": 11720.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11720.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11720.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18752.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11720.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11720.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15203 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11720.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17110.17 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3470.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24372.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16711.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11979.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23310, "minimum": 23310.59, "maximum": 42238.7891, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23310.59, "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": 23543.71, "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": 34396.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34189.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30303.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23310.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42238.79, "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": 34033.46, "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": 32774.69, "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": 23310.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24709.24, "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": 23310.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23310.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23310.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37296.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23310.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23310.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23466.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23310.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34396.84 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36981.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC", "code_information": [ { "code": "461", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51435, "minimum": 31950, "maximum": 97798.9, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51435.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 82297.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 51435.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51435.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80197 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 51435.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90260.45 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 51435.74, "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": 51950.06, "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": 90260.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 97798.9 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 66866.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 51435.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 93201.56, "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": 75096.18, "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": 72318.65, "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": 51435.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 54521.84, "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": 51435.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51435.74, "additional_payer_notes": "100.00% of Medicare 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45694.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC", "code_information": [ { "code": "462", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25153, "minimum": 9900, "maximum": 45578.8668, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 25153.9, "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": 25405.44, "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": 42121.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40824.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 32700.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45578.87, "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": 36724.69, "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": 35366.38, "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": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26663.13, "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": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40246.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27977.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 25153.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42121.64 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5000.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55169, "minimum": 55169.18, "maximum": 99966.5542, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 55169.18, "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": 55720.89, "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": 88777.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88597.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 71719.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 55169.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 99966.55, "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": 80547, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 77567.87, "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": 55169.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58479.35, "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": 55169.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55169.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55169.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88270.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 55169.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55169.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59136.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 55169.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88777.85 } ] } ] }, { "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": 15310, "minimum": 14850, "maximum": 27742.4086, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15310.38, "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": 15463.5, "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": 22814.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22449.93 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19903.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15310.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27742.41, "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": 22353.15, "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": 21526.39, "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": 15310.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.02, "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": 15310.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15310.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15310.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24496.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15310.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15310.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24405.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15310.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22814.05 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14449, "minimum": 9000, "maximum": 33902.8024, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14449.31, "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": 14593.79, "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": 21079.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20532.25 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18784.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14449.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26182.15, "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": 21095.99, "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": 20315.73, "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": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15316.26, "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": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14449.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23118.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20555.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21079.94 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17799, "minimum": 14850, "maximum": 32253.5094, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17799.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 17978, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26119.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26735.67 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23140, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17799.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32253.51, "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": 25987.93, "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": 25026.73, "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": 17800, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18868, "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": 17800, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17799.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17800, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28479.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17800, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17799.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19718.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17800, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26119.01 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9651, "minimum": 8612.26, "maximum": 21627.772, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9651.02, "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": 9747.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14218.52 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13733.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12546.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17487.65, "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": 14090.49, "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": 13569.33, "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": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10230.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 13050, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 13500, "10th_percentile": 13500, "90th_percentile": 13500, "count": "1 through 10" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15441.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8612.26 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9651.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14218.52 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11811.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12635, "minimum": 9805.1412, "maximum": 22895.3086, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22895.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18447.65, "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": 17765.34, "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": 12635.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13393.52, "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": 12635.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12635.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12635.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20216.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12635.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12635.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17067.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12635.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19209.05 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12635.38, "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": 12761.75, "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": 19209.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19384.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16426.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12635.38, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19097, "minimum": 14400, "maximum": 34603.8546, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19097.05, "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": 19287.97, "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": 29003.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28235.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24826.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19097.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34603.85, "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": 27881.69, "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": 26850.45, "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": 19097, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20242.82, "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": 19097, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19097.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19097, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30555.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19097, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19097.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26237.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19097, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29003.3 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4466.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8075.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33043, "minimum": 33043, "maximum": 59873.9885, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33043.04, "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": 33373.43, "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": 53666.19 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51961 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 42955.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 33043.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 59873.99, "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": 48242.84, "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": 46458.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33043, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35025.58, "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": 33043, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33043.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33043, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52868.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 33043, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33043.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38849.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33043, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53666.19 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7268.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7196.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19786, "minimum": 9752, "maximum": 35853.0655, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19786.46, "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": 19984.37, "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": 26423.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24120.91 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25722.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19786.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35853.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28888.23, "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": 27819.76, "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": 19786.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20973.69, "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": 19786.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19786.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19786.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31658.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19786.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19786.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14454.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19786.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26423.47 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11477, "minimum": 8528.264, "maximum": 20797.7736, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11477.8, "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": 11592.58, "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": 18570.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17798.44 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14921.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20797.77, "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": 16757.59, "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": 16137.79, "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": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12166.47, "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": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18364.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16500.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11477.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18570.7 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6886, "minimum": 5566.47, "maximum": 12477.5226, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6886.05, "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": 6954.91, "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": 10245.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9967.07 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8951.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12477.52, "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": 10053.63, "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": 9681.79, "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": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7299.21, "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": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11017.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5566.47 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6886.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10245.8 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3607.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "409", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20722, "minimum": 20700, "maximum": 37549.7136, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20722.8, "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": 20930.03, "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": 30835.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28073.88 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26939.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37549.71, "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": 30255.29, "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": 29136.26, "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": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21966.17, "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": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33156.48, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31897.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20722.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30835.96 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7363, "minimum": 4586.92, "maximum": 17516.0148, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7437.03, "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": 10948.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10483.42 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9572.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13342.48, "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": 10750.56, "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": 10352.94, "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": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7805.2, "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": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11781.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4586.92 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7363.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10948.86 } ] } ] }, { "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": 33467, "minimum": 33467.15, "maximum": 68667.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33467.15, "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": 33801.87, "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": 51498.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53388.14 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 43507.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 33467.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60642.48, "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": 48862.04, "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": 47054.81, "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": 33467.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35475.23, "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": 33467.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33467.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33467.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53547.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 33467.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33467.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68667.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33467.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51498.18 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17657.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32448, "minimum": 32448.19, "maximum": 58796.1203, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 32448.19, "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": 32772.68, "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": 50581.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48322.14 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 42182.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 32448.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 58796.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 47374.36, "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": 45622.16, "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": 32448.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34395.09, "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": 32448.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32448.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32448.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51917.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 32448.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32448.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52591.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 32448.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50581.86 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11033.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4573.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3644.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99001.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15123.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14612.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 MARROW HARVEST AUTOLOG", "code_information": [ { "code": "38232", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4101.56, "discounted_cash": 5574, "minimum": 150.04, "maximum": 4101.56, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "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": 4101.56, "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": 4101.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 150.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 150.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "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": 4101.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 160.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 150.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 150.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4101.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4913, "minimum": 4913.31, "maximum": 8902.9177, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 4913.31, "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": 4962.44, "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": 6496.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6306.69 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6387.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 8902.92, "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": 7173.43, "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": 6908.11, "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": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5208.11, "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": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7861.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5772.51 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 4913.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6496.66 } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8355, "minimum": 6548.38, "maximum": 15613.1016, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8355.74, "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": 8439.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12275.55 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11787.22 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10862.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15140.6, "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": 12199.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11748.17, "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": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8857.08, "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": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13369.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6548.38 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8355.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12275.55 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3384.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7489, "minimum": 6250.51, "maximum": 13570.376, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7489.17, "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": 7564.06, "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": 10873.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10681.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9735.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13570.38, "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": 10934.19, "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": 10529.77, "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": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7938.52, "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": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11982.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6250.51 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7489.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10873.85 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5199.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11759.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7984.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11788, "minimum": 8290.8428, "maximum": 21360.001, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11788.08, "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": 11905.98, "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": 17736.74 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17243.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15324.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11788.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21360, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17210.6, "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": 16574.04, "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": 11788.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12495.39, "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": 11788.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11788.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11788.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18860.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11788.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11788.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11291.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11788.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17736.74 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11205.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19256, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13054.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18444, "minimum": 9900, "maximum": 35612.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18444.37, "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": 18628.84, "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": 29197.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24153.9 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23977.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18444.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33421.2, "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": 26928.78, "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": 25932.78, "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": 18444.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19551.06, "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": 18444.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18444.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18444.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29510.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18444.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18444.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35612.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18444.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29197.45 } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20386, "minimum": 15300, "maximum": 37649.1, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20386.82, "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": 20590.67, "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": 30113.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28092.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26502.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20386.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36940.92, "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": 29764.76, "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": 28663.87, "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": 20386.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21610.01, "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": 20386.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20386.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20386.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32618.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20386.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20386.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37649.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20386.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30113.78 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8068.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16458.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10133.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24358.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8354.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55875, "minimum": 27900, "maximum": 101245.6812, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 89400.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 44356.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91109.12 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56433.85, "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": 91109.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89073.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 72637.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 101245.68, "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": 81577.65, "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": 78560.39, "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": 55875.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59227.61, "additional_payer_notes": "106.00% of Medicare 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17739.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14079.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9088.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16321.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29055.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27049.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 49689, "minimum": 25200, "maximum": 90037.8089, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 49689.74, "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": 50186.6, "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": 77905.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75224.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 64596.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 49689.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 90037.81, "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": 72547.02, "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": 69863.77, "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": 49689.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52671.08, "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": 49689.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 49689.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 49689.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 79503.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 49689.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 49689.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61710.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 49689.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77905.47 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2583.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10422.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "221", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47003, "minimum": 13950, "maximum": 85170.7406, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 47003.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47473.74, "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": 67549.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66675.65 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 61104.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 47003.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85170.74, "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": 68625.43, "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": 66087.23, "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": 47003.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 49823.92, "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": 47003.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47003.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47003.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75205.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 47003.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47003.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51372.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 47003.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67549.36 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4100.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30389.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51935.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34529.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6555, "minimum": 5850, "maximum": 12609.31, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6555.58, "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": 6621.14, "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": 10360.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10450.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8522.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11878.71, "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": 9571.15, "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": 9217.15, "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": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6948.91, "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": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10488.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9205.64 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6555.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10360.53 } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29579, "minimum": 21600, "maximum": 53598.054, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 29579.5, "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": 29875.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41264.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38849.91 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 38453.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53598.05, "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": 43186.07, "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": 41588.78, "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": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31354.27, "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": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47327.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36663.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 29579.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41264.15 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5736.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15073, "minimum": 9000, "maximum": 27313.2545, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27313.25, "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": 22007.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21193.4, "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": 15073.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15977.91, "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": 15073.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15073.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15073.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24117.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15073.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15073.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27142.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15073.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24098.09 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15073.54, "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": 15224.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24098.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22994.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19595.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15073.54, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30595, "minimum": 22330.586, "maximum": 69560.9, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30595.7, "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": 30901.66, "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": 50099.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47550.47 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 39774.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55439.41, "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": 44669.72, "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": 43017.55, "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": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32431.44, "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": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48953.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69560.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30595.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50099.43 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14162.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4137.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36267, "minimum": 21150, "maximum": 65717.471, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 36267.92, "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": 36630.58, "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": 57196.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55958.44 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 47148.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 36267.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 65717.47, "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": 52951.16, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 50992.7, "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": 36267.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38443.97, "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": 36267.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36267.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36267.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58028.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 36267.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36267.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50820 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 36267.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57196.18 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3863.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 2", "code_information": [ { "code": "1912", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9237.71, "maximum": 9884.35, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9884.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "217", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 61095, "minimum": 23400, "maximum": 110705.354, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 61095.67, "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": 61706.66, "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": 94984.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91298.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 79424.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 110705.35, "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": 89199.68, "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": 85900.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 64761.44, "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": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 97753.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61835.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94984.76 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4061.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15201, "minimum": 8690.0884, "maximum": 27544.4657, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15201.14, "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": 15353.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22024.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22042.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19761.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15201.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27544.47, "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": 22193.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 21372.8, "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": 15201.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16113.17, "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": 15201.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15201.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15201.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24321.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15201.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15201.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19568.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15201.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22024.21 } ] } ] }, { "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": 90539, "minimum": 48150, "maximum": 164058.4075, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 90539.96, "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": 91445.4, "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": 141951.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 139204.76 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 117702, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 90539.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 164058.41, "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": 132188.34, "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": 127299.18, "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": 90540, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 95972.4, "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": 90540, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 90539.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 90540, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 144863.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 90540, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 90539.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 135128 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 90540, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 141951.31 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5932, "minimum": 5309.82, "maximum": 10749.2732, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 5932.27, "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": 5991.59, "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": 8229.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7931.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7711.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10749.27, "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": 8661.11, "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": 8340.77, "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": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6288.21, "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": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9491.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5309.82 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5932.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8229.3 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9118, "minimum": 6686.7732, "maximum": 16522.8851, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9118.59, "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": 9209.78, "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": 13625.77 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13519.87 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11854.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16522.89, "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": 13313.14, "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": 12820.74, "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": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9665.71, "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": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14589.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10434.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9118.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13625.77 } ] } ] }, { "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": 71221, "minimum": 38250, "maximum": 129052.4882, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 71221.02, "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": 71933.21, "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": 113805.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110603.04 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 92587.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 71221.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 129052.49, "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": 103982.69, "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": 100136.75, "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": 71221, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 75494.26, "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": 71221, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 71221.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 71221, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 113953.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 71221, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 71221.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 89559.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 71221, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 113805.5 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20038.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15663.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47375.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 2", "code_information": [ { "code": "3832", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5117.1, "maximum": 5475.3, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5475.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11551.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": 19298, "minimum": 10800, "maximum": 38422.0736, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19298.09, "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": 19491.08, "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": 25852.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26772.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25087.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19298.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34968.14, "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": 28175.21, "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": 27133.11, "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": 19298.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20455.99, "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": 19298.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19298.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19298.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30876.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19298.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19298.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22970 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19298.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25852.79 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16150.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8730, "minimum": 6724.98, "maximum": 17388.4452, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8730.28, "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": 8817.58, "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": 12955.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12689.4 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11349.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15819.27, "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": 12746.21, "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": 12274.77, "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": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9254.1, "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": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13968.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6724.98 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8730.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12955.07 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 66191, "minimum": 37350, "maximum": 119938.7987, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 66191.39, "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": 66853.31, "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": 103943.58 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100915.67 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 86048.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 66191.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 119938.8, "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": 96639.43, "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": 93065.09, "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": 66191.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70162.88, "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": 66191.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66191.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66191.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 105906.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 66191.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66191.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 76668.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 66191.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103943.58 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18090, "minimum": 13500, "maximum": 32779.1344, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18090.03, "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": 18270.9, "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": 27910.48 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26990.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23517, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18090.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32779.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26411.44, "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": 25434.58, "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": 18090, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19175.4, "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": 18090, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18090.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18090, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28944.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18090, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18090.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32660.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18090, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27910.48 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18570, "minimum": 5400, "maximum": 33649.0756, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33649.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27112.39, "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": 26109.6, "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": 18570.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19684.31, "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": 18570.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18570.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18570.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29712.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18570.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18570.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26498.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18570.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26961.79 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18570.13, "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": 18755.8, "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": 26961.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25935.32 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24141.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18570.13, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45062, "minimum": 31950, "maximum": 81652.6883, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 45062.19, "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": 45512.82, "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": 71442.65 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70554.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 58580.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 45062.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 81652.69, "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": 65790.8, "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": 63357.44, "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": 45062.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47765.93, "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": 45062.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45062.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45062.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 72099.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 45062.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45062.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51864.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 45062.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71442.65 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43132, "minimum": 14850, "maximum": 78156.2531, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 43132.59, "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": 43563.93, "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": 68421.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68594.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 56072.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 43132.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 78156.25, "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": 62973.58, "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": 60644.42, "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": 43132.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45720.56, "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": 43132.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43132.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43132.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69012.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 43132.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43132.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63077.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43132.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68421.56 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40705.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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- SOI : 3", "code_information": [ { "code": "5393", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11858.17, "maximum": 12688.24, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12688.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19807.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34173.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41757.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15697, "minimum": 9000, "maximum": 36114.0088, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15697.77, "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": 15854.78, "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": 22324.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23598.82 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20407.14, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15697.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28444.36, "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": 22918.74, "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": 22071.06, "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": 15697.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16639.67, "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": 15697.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15697.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25116.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19835.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22324.26 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39473.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": 44838, "minimum": 24656.3688, "maximum": 81246.8184, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 44838.2, "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": 45286.58, "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": 73647.42 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69478.31 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 58289.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 81246.82, "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": 65463.77, "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": 63042.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47528.49, "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": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 71741.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59902 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 44838.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73647.42 } ] } ] }, { "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": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6057.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4318.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": 19897, "minimum": 17055.3468, "maximum": 36054.3425, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19897.54, "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": 20096.48, "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": 29831.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28710.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25866.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19897.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36054.34, "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": 29050.41, "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": 27975.94, "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": 19897.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21091.35, "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": 19897.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19897.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19897.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31836.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19897.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19897.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18306.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19897.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29831.38 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9226.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22679, "minimum": 8550, "maximum": 41096.0513, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22679.94, "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": 22906.7, "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": 33458.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32982.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 29483.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 22679.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41096.05, "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": 33112.71, "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": 31888, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22679.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24040.69, "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": 22679.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22679.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22679.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36287.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22679.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22679.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32366.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22679.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33458.45 } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13990, "minimum": 12109, "maximum": 38210.6388, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13990.32, "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": 14130.2, "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": 20156.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18690.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18187.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13990.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25350.46, "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": 20425.87, "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": 19670.39, "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": 13990.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14829.72, "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": 13990.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13990.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13990.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22384.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13990.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13990.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12109 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13990.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20156.26 } ] } ] }, { "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": 61095, "minimum": 10350, "maximum": 110705.354, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 61095.67, "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": 61706.66, "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": 87504.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81708.73 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 79424.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 110705.35, "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": 89199.68, "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": 85900.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 64761.44, "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": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 97753.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77748.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 61095.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87504.11 } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13782, "minimum": 10287.0708, "maximum": 24974.5242, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13782.85, "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": 13920.73, "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": 21609.44 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21335.46 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17917.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13782.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24974.52, "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": 20122.96, "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": 19378.69, "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": 13782.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14609.87, "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": 13782.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13782.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13782.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22052.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13782.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13782.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14942.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13782.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21609.44 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12744, "minimum": 10033.1128, "maximum": 23093.2514, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12744.62, "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": 12872.05, "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": 18689.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17392.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16567.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12744.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23093.25, "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": 18607.15, "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": 17918.94, "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": 12744.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13509.28, "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": 12744.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12744.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12744.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20391.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12744.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12744.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10639.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12744.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18689.84 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61903.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5120.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86425.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15877, "minimum": 7540, "maximum": 25093.37, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15877.69, "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": 16036.48, "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": 23767.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25093.37 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20641.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15877.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 23181.43, "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": 22324.03, "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": 15877.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16830.36, "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": 15877.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15877.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15877.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15877.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15877.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15877.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23767.15 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6438.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75975.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9537, "minimum": 7540, "maximum": 13924.2974, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10109.42, "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": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11696.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13306.6 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9537.19, "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": 9632.56, "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": 13306.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12263.41 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12398.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 13924.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13409.29, "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": 9537.19, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 397146, "minimum": 55350, "maximum": 719628.7332, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 397146.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 401117.46, "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": 554691.33 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 528441.07 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 516289.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 397146.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 719628.73, "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": 579833.31, "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": 558387.42, "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": 397146, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 420974.76, "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": 397146, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 397146.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 397146, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 635433.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 397146, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 397146.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 427639 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 397146, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 554691.33 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6255.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7345, "minimum": 7345.04, "maximum": 13309.2125, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7345.04, "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": 7418.49, "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": 10492.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10378.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9548.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13309.21, "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": 10723.76, "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": 10327.13, "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": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7785.74, "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": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11752.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7716.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7345.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10492.9 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20036, "minimum": 19800, "maximum": 36305.5038, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20036.15, "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": 20236.56, "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": 31352.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29634.42 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26047.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20036.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36305.5, "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": 29252.78, "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": 28170.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20036.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21238.37, "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": 20036.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20036.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20036.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32057.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20036.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20036.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27857.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20036.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31352.22 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23146, "minimum": 7200, "maximum": 41941.0594, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23146.28, "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": 23377.76, "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": 34820.44 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35292.8 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30090.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23146.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41941.06, "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": 33793.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 32543.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23146.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24535.08, "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": 23146.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23146.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23146.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37034.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23146.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23146.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27738.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23146.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34820.44 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4284.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15978, "minimum": 12600, "maximum": 28953.35, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15978.67, "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": 16138.49, "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": 24452.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21652.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20772.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15978.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28953.35, "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": 23328.86, "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": 22466.01, "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": 15978.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16937.42, "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": 15978.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15978.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15978.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25565.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15978.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15978.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21726.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15978.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24452.56 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10014.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19707, "minimum": 19707.5, "maximum": 35710.0081, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19707.51, "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": 19904.58, "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": 29094.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28339.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25619.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19707.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35710.01, "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": 28772.96, "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": 27708.76, "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": 19707.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20889.95, "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": 19707.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19707.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19707.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31532.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19707.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19707.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26433.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19707.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29094.5 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9964.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10467, "minimum": 7540, "maximum": 15929.0932, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10571.77, "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": 15929.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14688.84 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13607.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 15281.97, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 14716.74, "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": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11095.13, "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": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10812.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10467.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15929.09 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33439, "minimum": 33439.6, "maximum": 60592.5733, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 33439.61, "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": 33774, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51534.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50562.54 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 43471.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 33439.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 60592.57, "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": 48821.83, "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": 47016.09, "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": 33439.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35445.98, "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": 33439.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33439.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33439.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53503.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 33439.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33439.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 45789.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 33439.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51534.96 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17464.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5896.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5273.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4122.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4006.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26040.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7925.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8272.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10987, "minimum": 7540, "maximum": 16041.896, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10987.6, "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": 11097.48, "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": 15617.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15076.1 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14283.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 16041.9, "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": 15448.57, "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": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11646.86, "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": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16004.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10987.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15617.28 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13304.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15580.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15335.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8532, "minimum": 8532.91, "maximum": 32004.614, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8532.91, "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": 8618.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12044.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11993.76 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11092.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15461.63, "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": 12458.05, "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": 11997.27, "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": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9044.88, "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": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13652.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8580.47 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8532.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12044.63 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7276, "minimum": 7276.19, "maximum": 13184.4563, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7276.19, "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": 7348.95, "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": 10244.33 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9602.75 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9459.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13184.46, "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": 10623.24, "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": 10230.32, "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": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7712.76, "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": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11641.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7826.98 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7276.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10244.33 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4926.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27780, "minimum": 11250, "maximum": 50337.813, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 36114.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 27780.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50337.81, "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": 40559.17, "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": 39059.03, "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": 27780.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 29447.12, "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": 27780.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27780.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27780.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 44448.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 27780.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27780.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32464 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 27780.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42612.9 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 27780.25, "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": 28058.1, "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": 42612.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42389.8 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8608.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8474, "minimum": 8474.16, "maximum": 15355.1779, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8474.16, "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": 8558.9, "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": 12635.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12177.35 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11016.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15355.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12372.27, "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": 11914.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8982.61, "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": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13558.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9458.77 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8474.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12635.9 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5767.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31059, "minimum": 25650, "maximum": 56279.4154, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 31059.28, "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": 31369.89, "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": 40247.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43608.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 40377.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 31059.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56279.42, "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": 45346.55, "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": 43669.35, "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": 31059.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32922.86, "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": 31059.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31059.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31059.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49694.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 31059.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31059.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35760.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 31059.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40247.8 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18803, "minimum": 18803.3, "maximum": 34071.5796, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18803.3, "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": 18991.33, "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": 28815.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27481.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24444.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34071.58, "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": 27452.82, "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": 26437.44, "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": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19931.5, "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": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30085.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23323.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18803.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28815.04 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22526.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12766.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20524.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23272, "minimum": 7540, "maximum": 33978.5216, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23272.96, "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": 23505.73, "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": 27094.17 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25413.23 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30254.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 33978.52, "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": 32721.78, "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": 23273, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24669.38, "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": 23273, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23273, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23273, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23272.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17137.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23273, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27094.17 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21048, "minimum": 12640.0212, "maximum": 38140.2263, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21048.69, "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": 21259.19, "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": 32553.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30918.13 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 27363.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21048.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38140.23, "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": 30731.09, "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": 29594.46, "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": 21048.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22311.62, "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": 21048.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21048.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21048.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33677.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21048.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21048.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23998.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21048.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32553.89 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2942.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9528, "minimum": 7540, "maximum": 13910.8946, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8971.35 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12847.7 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9528.01, "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": 9623.29, "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": 12847.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12425.49 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12386.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 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": 13910.89, "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": 13396.38, "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": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10099.69, "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": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9528.01, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10431, "minimum": 10431.3, "maximum": 18901.5156, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10431.3, "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": 10535.61, "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": 15734.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14787.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13560.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18901.52, "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": 15229.7, "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": 14666.41, "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": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11057.18, "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": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16690.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11882.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10431.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15734.94 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 87727.12, "maximum": 87727.12, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87727.12 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20648.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7254.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7701.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66058.9, "maximum": 66058.9, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66058.9 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16147.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9051.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6504.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18748, "minimum": 17624.8, "maximum": 33971.7746, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18748.22, "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": 18935.68, "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": 28303.19 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27947.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24372.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18748.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33971.77, "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": 27372.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 26360, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18748.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19873.09, "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": 18748.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18748.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18748.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29997.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18748.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18748.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17624.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18748.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28303.19 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17792.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11994.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9936, "minimum": 8131.3808, "maximum": 18004.9561, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9936.51, "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": 10035.88, "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": 14942.17 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14827.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12917.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18004.96, "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": 14507.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13970.73, "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": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10532.7, "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": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15898.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9723.67 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9936.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14942.17 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8084, "minimum": 6980.47, "maximum": 14649.9113, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8084.94, "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": 8165.79, "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": 11020.93 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10859.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10510.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14649.91, "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": 11804.01, "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": 11367.43, "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": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8570.04, "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": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12935.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6980.47 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8084.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11020.93 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24534, "minimum": 15452.4584, "maximum": 44456.0972, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 24534.27, "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": 24779.64, "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": 37562.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35054.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31894.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24534.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44456.1, "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": 35820.03, "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": 34495.18, "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": 24534.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26006.36, "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": 24534.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24534.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24534.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39254.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24534.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24534.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18359.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 24534.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37562.07 } ] } ] }, { "description": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14737, "minimum": 14729.7, "maximum": 26704.4587, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14737.56, "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": 14884.98, "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": 22768.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22375.34 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19158.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14737.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26704.46, "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": 21516.84, "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": 20721.01, "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": 14737.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15621.86, "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": 14737.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14737.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14737.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23580.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14737.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14737.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14729.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14737.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22768.45 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7054, "minimum": 7054.96, "maximum": 20663.9128, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7054.96, "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": 7125.51, "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": 10114.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10008.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9171.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12783.59, "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": 10300.24, "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": 9919.27, "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": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7478.26, "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": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11287.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7077 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7054.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10114.9 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4760.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10139.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8292, "minimum": 8292.4, "maximum": 15025.8288, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8375.32, "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": 12609.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13407.99 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10780.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15025.83, "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": 12106.9, "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": 11659.11, "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": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8789.94, "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": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13267.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14672 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8292.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12609.43 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17798.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 127100.56, "maximum": 127100.56, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 127100.56 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7401.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12232.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13250, "minimum": 12600, "maximum": 26749.2, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13250.42, "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": 13382.9, "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": 20153.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19208.37 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17225.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13250.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24009.76, "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": 19345.61, "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": 18630.09, "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": 13250.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14045.42, "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": 13250.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13250.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13250.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21200.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13250.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13250.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26749.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13250.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20153.32 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17541, "minimum": 11839.1676, "maximum": 31786.0859, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17541.99, "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": 17717.42, "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": 26822.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26171.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22804.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17541.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31786.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25611.31, "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": 24664.04, "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": 17542, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18594.52, "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": 17542, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17541.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17542, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28067.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17542, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17541.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16787.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17542, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26822.06 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23517, "minimum": 13623.9608, "maximum": 42613.0577, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23517.14, "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": 23752.27, "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": 37166.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35760.39 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30572.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23517.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42613.06, "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": 34335.02, "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": 33065.1, "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": 23517.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24928.13, "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": 23517.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23517.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23517.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37627.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23517.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23517.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28537.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23517.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37166.41 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28929.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37673.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11323, "minimum": 9877.1944, "maximum": 20518.327, "payers_information": [ { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11323.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20518.33, "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": 16532.43, "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": 15920.95, "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": 11323.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12003.02, "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": 11323.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11323.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11323.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18117.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11323.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11323.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14796.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11323.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17027.8 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11323.58, "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": 11436.84, "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": 17027.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17201.76 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14720.68, "additional_payer_notes": "130.00% of Medicare 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9554.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5915.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 70917, "minimum": 50850, "maximum": 128501.8939, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 70917.16, "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": 71626.37, "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": 114965.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111870.98 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 92192.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 70917.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 128501.89, "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": 103539.05, "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": 99709.53, "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": 70917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 75172.23, "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": 70917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 70917.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 70917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 113467.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 70917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 70917.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 92391.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 70917.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114965.99 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6569.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41266.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10904, "minimum": 10631.4, "maximum": 19758.1567, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10904.06, "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": 11013.14, "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": 16517.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15806.17 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10904.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19758.16, "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": 15919.93, "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": 15331.11, "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": 10904.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11558.35, "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": 10904.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10904.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17446.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10631.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10904.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16517.43 } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56389, "minimum": 34200, "maximum": 102177.176, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 56389.17, "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": 56953.09, "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": 89848.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85321.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 73305.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 56389.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 102177.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 82328.19, "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": 79283.17, "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": 56389.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59772.55, "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": 56389.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56389.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56389.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 90222.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 56389.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56389.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79832.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56389.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89848.62 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50216.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 50882, "minimum": 36450, "maximum": 92198.5464, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 50882.2, "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": 51391.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 78251.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74554.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 66146.86, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 92198.55, "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": 74288.01, "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": 71540.37, "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": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53935.13, "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": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 81411.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 75779.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 50882.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78251.12 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6629, "minimum": 5894.96, "maximum": 12011.7842, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6629.02, "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": 6695.31, "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": 9519.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9205.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8617.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12011.78, "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": 9678.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 9320.4, "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": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7026.76, "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": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10606.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5894.96 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6629.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9519.21 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 39188, "minimum": 26100, "maximum": 71008.6922, "payers_information": [ { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 39188, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60482.02 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 39188.02, "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": 39579.88, "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": 60482.02 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57963.61 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 50944.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 39188.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 71008.69, "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": 57214.51, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 55098.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39188, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41539.28, "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": 39188, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39188.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 39188, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 62700.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 39188, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39188.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 57543.8 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68115.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54608, "minimum": 36450, "maximum": 98950.2215, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 54608.29, "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": 55154.38, "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": 86546.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84346.44 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 70990.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 54608.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 98950.22, "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": 79728.1, "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": 76779.26, "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": 54608.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57884.8, "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": 54608.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 54608.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 54608.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 87373.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 54608.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 54608.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 71198.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 54608.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86546.6 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10558, "minimum": 9450, "maximum": 31965.6344, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10558.9, "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": 10664.49, "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": 16027.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15513.57 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13726.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19132.73, "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": 15415.99, "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": 14845.81, "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": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11192.43, "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": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16894.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14270.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10558.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16027.64 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58900.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 78120, "minimum": 48600, "maximum": 141554.4728, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 78120.57, "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": 78901.81, "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": 124636.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 116397.68 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 101556.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 78120.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 141554.47, "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": 114056.03, "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": 109837.52, "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": 78120.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 82807.84, "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": 78120.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 78120.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 78120.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 124992.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 78120.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 78120.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69749.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 78120.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 124636.7 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35377.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40460, "minimum": 20700, "maximum": 73314.1361, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 40460.34, "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": 40864.9, "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": 62648.55 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59380.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 52598.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 40460.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73314.14, "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": 59072.1, "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": 56887.24, "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": 40460.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42887.92, "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": 40460.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40460.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40460.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64736.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 40460.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40460.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62269.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 40460.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62648.55 } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10198, "minimum": 10198.1, "maximum": 18479.0116, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10198.13, "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": 10300.08, "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": 15331.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14718.96 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13257.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10198.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18479.01, "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": 14889.27, "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": 14338.57, "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": 10198.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10809.99, "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": 10198.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10198.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10198.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16317.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10198.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10198.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11031.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10198.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15331.94 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42758.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11349.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11559.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29277, "minimum": 13500, "maximum": 53050.7938, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 29277.48, "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": 29570.28, "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": 44986.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42356.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 38060.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 29277.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53050.79, "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": 42745.12, "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": 41164.14, "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": 29277.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31034.15, "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": 29277.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29277.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29277.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 46843.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 29277.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29277.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33438.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 29277.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44986.82 } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29661, "minimum": 10350, "maximum": 58911.1688, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 41703.65, "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": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31440.87, "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": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47457.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46938.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46994.5 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 29661.2, "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": 29957.81, "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": 46994.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42579.13 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 38559.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 29661.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 53746.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 43305.35, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5375.6412, "maximum": 11616.6185, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11616.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11432.94 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10321.8 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11616.62 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36109.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30206, "minimum": 12150, "maximum": 54734.1418, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30206.48, "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": 30508.57, "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": 42096.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37927.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 39268.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30206.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 54734.14, "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": 44101.46, "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": 42470.31, "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": 30206.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32018.89, "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": 30206.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30206.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30206.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48330.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30206.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30206.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37403 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30206.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42096.64 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8254.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30075.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8637.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6377.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58842.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15462, "minimum": 15462.76, "maximum": 28018.5211, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15462.76, "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": 15617.43, "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": 22733.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21701.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20101.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15462.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28018.52, "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": 22575.63, "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": 21740.64, "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": 15462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16390.57, "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": 15462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15462.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24740.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15462.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17716.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15462.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22733.15 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10681, "minimum": 10681.9, "maximum": 19355.6209, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10681.91, "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": 10788.72, "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": 16018.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15390.22 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13886.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10681.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19355.62, "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": 15595.59, "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": 15018.77, "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": 10681.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11322.81, "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": 10681.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10681.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10681.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17091.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10681.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10681.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11820.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10681.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16018.81 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22061, "minimum": 22061.2, "maximum": 39974.9306, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 22061.22, "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": 22281.81, "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": 36831.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34337.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 28679.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 22061.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39974.93, "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": 32209.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 31018.08, "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": 22061.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23384.87, "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": 22061.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22061.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22061.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35297.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22061.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22061.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28487 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 22061.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36831.06 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42473, "minimum": 29250, "maximum": 76961.9458, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 42473.48, "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": 42898.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 65779.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63339.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 55215.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 42473.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76961.95, "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": 62011.28, "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": 59717.71, "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": 42473.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45021.91, "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": 42473.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42473.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42473.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 67957.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 42473.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42473.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 50300.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 42473.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65779.95 } ] } ] }, { "description": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 100557, "minimum": 56250, "maximum": 182210.9148, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 100557.9, "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": 101563.58, "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": 160230.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 154485.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 130725.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 100557.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 182210.91, "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": 146814.53, "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": 141384.41, "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": 100558, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 106591.48, "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": 100558, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 100557.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 100558, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 160892.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 100558, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 100557.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 142367 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 100558, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 160230.79 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9087, "minimum": 9087.37, "maximum": 29813.488, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9087.37, "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": 9178.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13834.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13461.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11813.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16466.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13267.56, "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": 12776.84, "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": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9632.61, "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": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14539.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9662.45 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9087.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13834.63 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24176.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CONCUSSION WITH CC", "code_information": [ { "code": "089", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10820, "minimum": 10820.5, "maximum": 19606.8004, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10820.53, "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": 10928.71, "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": 15768.77 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16493.21 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14066.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10820.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19606.8, "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": 15797.97, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 15213.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10820.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11469.73, "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": 10820.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10820.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10820.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17312.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10820.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10820.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17909.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10820.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15768.77 } ] } ] }, { "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": 36646, "minimum": 17550, "maximum": 66402.7876, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 36646.13, "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": 37012.56, "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": 55916.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54343.4 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 47639.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 36646.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 66402.79, "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": 53503.35, "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": 51524.46, "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": 36646.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38844.87, "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": 36646.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36646.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36646.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58633.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 36646.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36646.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 45895.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 36646.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55916.56 } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13144, "minimum": 13144.86, "maximum": 23818.4863, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13144.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13276.35, "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": 20749 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21999.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17088.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13144.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23818.49, "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": 19191.5, "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": 18481.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13933.59, "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": 13144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13144.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21031.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13144.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18436 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20749 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18794.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10491.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18125.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5927.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13409.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23431.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4343.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10708.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19545, "minimum": 13436.15, "maximum": 35417.2614, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 19545.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19741.46, "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": 28740.03 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26999.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25409.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19545.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35417.26, "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": 28537.09, "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": 27481.61, "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": 19546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20718.76, "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": 19546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19545.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31273.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19545.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17947.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 19546, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28740.03 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8411, "minimum": 8411.74, "maximum": 22807.7908, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8916.44, "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": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13458.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9514.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10975.34 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8411.74, "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": 8495.86, "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": 10975.34 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11808.73 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10935.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15242.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12281.14, "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": 11826.91, "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": 8411.74, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8962, "minimum": 7337.6144, "maximum": 16240.1044, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8962.53, "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": 9052.16, "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": 13490.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12900.25 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11651.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16240.1, "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": 13085.29, "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": 12601.32, "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": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9500.28, "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": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14340.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7456.11 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8962.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13490.46 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7239, "minimum": 6861.55, "maximum": 22610.5304, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7239.48, "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": 7311.87, "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": 9701.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9684.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9411.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13117.94, "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": 10569.64, "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": 10178.71, "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": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7673.85, "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": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11583.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6861.55 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7239.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9701.6 } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11177, "minimum": 5121.44, "maximum": 20518.6252, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11177.62, "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": 11289.38, "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": 15073.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14858.09 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14530.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11177.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20253.85, "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": 16319.33, "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": 15715.73, "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": 11177.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11848.26, "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": 11177.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11177.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11177.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17884.19, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11177.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11177.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5121.44 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11177.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15073.07 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13924, "minimum": 10585.9144, "maximum": 25230.6866, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13924.22, "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": 14063.44, "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": 21419.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20787.55 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18101.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13924.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25230.69, "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": 20329.36, "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": 19577.45, "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": 13924.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14759.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 18000, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 13500, "10th_percentile": 13500, "90th_percentile": 13500, "count": "1 through 10" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13924.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13924.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13924.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22278.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13924.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13924.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12590.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13924.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21419.7 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3519.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16488.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16922.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35709.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31852.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9220, "minimum": 9220.48, "maximum": 16707.5098, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9220.48, "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": 9312.68, "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": 12987.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12785.5 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11986.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16707.51, "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": 13461.9, "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": 12963.99, "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": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9773.71, "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": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14752.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10458.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9220.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12987.43 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7940.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "027", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23895, "minimum": 7200, "maximum": 43298.3742, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23895.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38232.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23895.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23895.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33383.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23895.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36297.15 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23895.35, "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": 24134.25, "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": 36297.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34895.5 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31063.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23895.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43298.37, "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": 34887.21, "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": 33596.86, "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": 23895.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25329.02, "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": 23895.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23895.35, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 2", "code_information": [ { "code": "5172", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8522.14, "maximum": 9118.69, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9118.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12628, "minimum": 12628.95, "maximum": 22883.6574, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12628.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12755.29, "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": 19626.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19552.61 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12628.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22883.66, "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": 18438.27, "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": 17756.3, "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": 12629, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13386.74, "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": 12629, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12628.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12629, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20206.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12629, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12628.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19023.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12629, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19626.76 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 62525, "minimum": 39600, "maximum": 117851, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 62525.89, "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": 63151.16, "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": 100432.71 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87352.77 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 81283.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 62525.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 113296.91, "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": 91287.8, "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": 87911.4, "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": 62525.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66277.45, "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": 62525.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 62525.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 62525.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 100041.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 62525.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 62525.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 117851 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 62525.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100432.71 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15325.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7411.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24235.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16983.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9372, "minimum": 5401.65, "maximum": 18000, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9372.87, "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": 9466.6, "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": 13444.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13002.08 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12184.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16983.64, "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": 13684.39, "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": 13178.26, "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": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9935.24, "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": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14996.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5401.65 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9372.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13444.86 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60978.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 53338, "minimum": 32850, "maximum": 96649.7606, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 53338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53872.09, "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": 83912.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81308.56 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 69340.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 53338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 96649.76, "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": 77874.53, "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": 74994.24, "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": 53338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56539.02, "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": 53338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 85341.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 53338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53338.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 74519.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 53338.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83912.35 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10684.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6997.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "441", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17210, "minimum": 17210.6, "maximum": 31185.6072, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17210.6, "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": 17382.71, "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": 27804.58 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26222.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22373.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31185.61, "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": 25127.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 24198.1, "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": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18243.24, "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": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27536.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21292.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17210.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27804.58 } ] } ] }, { "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": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7909.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7596.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "443", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7158, "minimum": 7071.12, "maximum": 12971.5463, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7158.69, "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": 7230.28, "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": 10335.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10251.06 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9306.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12971.55, "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": 10451.69, "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": 10065.12, "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": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7588.21, "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": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11453.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7071.12 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7158.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10335.53 } ] } ] }, { "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": 9596, "minimum": 9596.85, "maximum": 17389.4922, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9596.85, "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": 9692.82, "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": 14211.16 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13647.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12475.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17389.49, "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": 14011.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 13493.17, "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": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10172.66, "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": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15354.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10979.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9596.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14211.16 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20198.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4804.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6417.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15700, "minimum": 15700.5, "maximum": 28449.3422, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15700.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15857.51, "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": 24470.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23935.88 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20410.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15700.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28449.34, "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": 22922.76, "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": 22074.93, "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": 15700.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16642.53, "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": 15700.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15700.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15700.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25120.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15700.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15700.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19221.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15700.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24470.21 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21405.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7488.808, "maximum": 18061.7973, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18061.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15687.12 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16048.4 }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18061.8 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8152.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6439, "minimum": 6439.91, "maximum": 11669.1169, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6439.91, "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": 6504.31, "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": 9047.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8829.65 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8371.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11669.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9402.27, "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": 9054.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6826.3, "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": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10303.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6743.82 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6439.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9047.08 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43439.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3928.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11839, "minimum": 11839.49, "maximum": 21453.1559, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11839.49, "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": 11957.9, "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": 18072.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17187.42 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15391.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11839.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21453.16, "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": 17285.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 16646.32, "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": 11839.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12549.87, "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": 11839.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11839.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18943.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13511.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11839.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18072.09 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6320.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30129.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10781, "minimum": 10343, "maximum": 19536.9296, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14016.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10781.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19536.93, "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": 15741.68, "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": 15159.45, "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": 10782, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11428.92, "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": 10782, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10781.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10782, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17251.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10782, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10781.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10343 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10782, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15951.16 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10781.97, "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": 10889.82, "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": 15951.16 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15588.16 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20368, "minimum": 20368.46, "maximum": 36907.6495, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20368.46, "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": 20572.19, "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": 31055.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30106.31 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26479.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20368.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36907.65, "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": 29737.95, "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": 28638.05, "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": 20368.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21590.61, "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": 20368.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20368.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20368.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32589.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20368.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20368.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25581.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20368.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31055.11 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19709.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52892.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6239.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3014.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16495, "minimum": 16495.49, "maximum": 52939.0216, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16495.49, "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": 16660.46, "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": 24084.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24483.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21444.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16495.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29889.83, "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": 24083.42, "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": 23192.66, "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": 16495.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17485.23, "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": 16495.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16495.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16495.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26392.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16495.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16495.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19029.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16495.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24084.85 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16765.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35645.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2306.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18785, "minimum": 12296, "maximum": 34039.9783, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18785.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18973.76, "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": 27267.72 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26899.18 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24421.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18785.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34039.98, "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": 27427.36, "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": 26412.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18785.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19913.05, "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": 18785.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18785.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18785.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30057.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18785.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18785.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14433 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18785.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27267.72 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8052, "minimum": 8052.81, "maximum": 14591.6917, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8052.81, "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": 8133.34, "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": 11776.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12761.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10468.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14591.69, "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": 11757.1, "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": 11322.25, "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": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8535.98, "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": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12884.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10464.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8052.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11776.94 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4664.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11002.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13959.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22540.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25628.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34882.21, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41598.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13060.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39534.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3615.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11768.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20172, "minimum": 8877.8992, "maximum": 36553.3492, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 20172.93, "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": 20374.63, "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": 33742.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30278.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26224.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20172.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36553.35, "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": 29452.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 28363.14, "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": 20172.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21383.27, "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": 20172.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20172.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20172.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32276.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20172.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20172.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16781.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 20172.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33742.32 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10144, "minimum": 9075.1596, "maximum": 18382.5407, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10144.89, "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": 10246.35, "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": 15199.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15228.14 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13188.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10144.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18382.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14811.54, "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": 14263.72, "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": 10144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10753.59, "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": 10144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10144.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16231.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10144.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9664.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10144.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15199.56 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12407, "minimum": 12407.7, "maximum": 22482.7886, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12407.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12531.78, "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": 18308.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17725.29 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16130.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12407.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22482.79, "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": 18115.27, "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": 17445.25, "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": 12407.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13152.16, "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": 12407.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12407.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12407.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19852.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12407.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12407.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14320 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12407.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18308.9 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14781.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44438, "minimum": 4764.71, "maximum": 81241.7548, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 44438.88, "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": 44883.29, "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": 69198.16 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69997.53 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 57770.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 44438.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 80523.25, "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": 64880.76, "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": 62481.07, "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": 44438.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47105.23, "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": 44438.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44438.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44438.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 71102.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 44438.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44438.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4764.71 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 44438.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69198.16 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6861.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27742.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8331.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18711.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56993, "minimum": 11700, "maximum": 103271.6965, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 56993.21, "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": 57563.13, "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": 88114.51 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89588.87 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 74091.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 56993.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 103271.7, "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": 83210.09, "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": 80132.45, "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": 56993.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 60412.79, "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": 56993.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56993.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56993.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91189.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 56993.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56993.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 49454.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 56993.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88114.51 } ] } ] }, { "description": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6438, "minimum": 5399.3, "maximum": 15776.1072, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8369.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11665.8, "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": 9399.6, "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": 9051.94, "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": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6824.36, "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": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10300.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5399.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6438.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9216.22 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6438.08, "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": 6502.46, "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": 9216.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8928.62 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31364.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7715.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13868.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10881.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16073.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15846, "minimum": 12107.3, "maximum": 28713.8218, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15846.48, "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": 16004.97, "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": 24376.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23595.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20600.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15846.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28713.82, "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": 23135.86, "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": 22280.15, "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": 15846.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16797.29, "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": 15846.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15846.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15846.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25354.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15846.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15846.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17455.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15846.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24376.07 } ] } ] }, { "description": "EPISTAXIS WITH MCC", "code_information": [ { "code": "150", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12958, "minimum": 8719.6184, "maximum": 23480.8201, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12958.51, "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": 13088.09, "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": 20329.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18854.1 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16846.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12958.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23480.82, "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": 18919.42, "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": 18219.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12958.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13736.01, "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": 12958.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12958.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12958.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20733.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12958.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12958.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18062.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12958.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20329.82 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58548.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EPISTAXIS WITHOUT MCC", "code_information": [ { "code": "151", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7473, "minimum": 5863.16, "maximum": 18468.062, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7473.56, "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": 7548.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11148.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11054.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9715.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13542.09, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10911.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 10507.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7921.97, "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": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11957.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5863.16 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7473.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11148.89 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6599.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC", "code_information": [ { "code": "981", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43805, "minimum": 29039.802, "maximum": 79375.5116, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 43805.47, "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": 44243.56, "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": 69921.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67992.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 56947.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 43805.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 79375.51, "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": 63955.99, "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": 61590.49, "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": 43805.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46433.83, "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": 43805.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43805.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43805.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 70088.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 43805.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43805.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 65905.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 43805.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69921.81 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13719.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4835.55, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23482.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE", "code_information": [ { "code": "790", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55295, "minimum": 8647.58, "maximum": 100196.0983, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 55295.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 55848.86, "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": 87437.93 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86060.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 71884.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 55295.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 100196.1, "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": 80731.96, "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": 77745.98, "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": 55295.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58613.65, "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": 55295.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55295.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55295.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 88473.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 55295.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55295.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8647.58 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 55295.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87437.93 } ] } ] }, { "description": "Expl N/Flwd Surg Uxtr Art", "code_information": [ { "code": "35702", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18375, "minimum": 351.08, "maximum": 18375, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 351.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 351.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 375.66 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 351.08 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 351.08 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11961.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 185129.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12378, "minimum": 12193.7, "maximum": 22429.5521, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12378.34, "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": 12502.08, "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": 18892.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18297.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16091.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12378.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22429.55, "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": 18072.38, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17403.95, "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": 12378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13121, "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": 12378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12378.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19805.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12378.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12193.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12378.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18892.82 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22679.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20197.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Exc H-F-Nk-Sp B9+Marg 0.6-1", "code_information": [ { "code": "11421", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15750, "discounted_cash": 906, "minimum": 96.12, "maximum": 15750, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 96.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 96.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9067.65, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 196729, "minimum": 84723.9324, "maximum": 378067.28, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 196729.41, "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": 198696.29, "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": 348922.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 378067.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 255747.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 196729.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 356473.69, "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": 287224.94, "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": 276601.55, "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": 196729, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 208532.74, "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": 196729, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 196729.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 196729, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 314767.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 196729, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 196729.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 310021 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 196729, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 348922.15 } ] } ] }, { "description": "Excision Olecranon Bursa", "code_information": [ { "code": "24105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 4187, "minimum": 290.51, "maximum": 10500, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5636.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16847.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17908.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29224.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18253.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES", "code_information": [ { "code": "748", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13470, "minimum": 6300, "maximum": 30328.4912, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13470.74, "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": 13605.41, "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": 20037.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20150.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17511.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13470.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24408.98, "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": 19667.28, "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": 18939.86, "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": 13470.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14278.94, "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": 13470.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13470.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13470.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21553.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13470.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13470.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22702.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13470.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20037.12 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47876.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31288.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10043.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16355.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12858.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 36483, "minimum": 11700, "maximum": 66108.3557, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 36483.64, "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": 36848.44, "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": 63641.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43488.49 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 47428.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 36483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 66108.36, "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": 53266.11, "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": 51296, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38672.62, "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": 36483.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58373.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 56546.6 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 36483.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63641.36 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8457, "minimum": 8457.64, "maximum": 15325.2437, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8457.64, "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": 8542.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12652.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12266.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10994.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15325.24, "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": 12348.15, "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": 11891.44, "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": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8965.1, "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": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13532.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8972.52 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8457.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12652.08 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41460.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13285, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16074, "minimum": 15765.8, "maximum": 29126.3417, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16074.14, "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": 16234.84, "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": 24774.67 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23425.26 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16074.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29126.34, "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": 23468.24, "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": 22600.24, "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": 16074.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17038.55, "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": 16074.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16074.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16074.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25718.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16074.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16074.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15765.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16074.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24774.67 } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS", "code_information": [ { "code": "864", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8884, "minimum": 7436.09, "maximum": 17697.9196, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8884.5, "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": 8973.35, "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": 13208.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12662.15 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11549.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16098.71, "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": 12971.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 12491.61, "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": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9417.57, "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": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14215.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7436.09 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8884.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13208.06 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42501.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16380.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8330, "minimum": 7885.84, "maximum": 15094.0325, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8330.04, "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": 8413.34, "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": 11726.93 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11496.05 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10829.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15094.03, "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": 12161.86, "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": 11712.04, "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": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8829.84, "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": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13328.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7885.84 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8330.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11726.93 } ] } ] }, { "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": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8663.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57464, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12506.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FOOT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "505", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17193, "minimum": 16880.7, "maximum": 31154.0059, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17193.16, "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": 17365.13, "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": 25813.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24465.14 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22351.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17193.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31154.01, "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": 25102.01, "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": 24173.58, "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": 17193.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18224.79, "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": 17193.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17193.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27509.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16880.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17193.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25813.07 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 117818.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70864.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "038", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15630, "minimum": 8550, "maximum": 28322.919, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15630.75, "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": 15787.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23699.49 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22947.64 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20320.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15630.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28322.92, "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": 22820.9, "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": 21976.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15630.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16568.65, "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": 15630.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15630.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15630.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25009.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15630.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15630.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23590.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15630.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23699.49 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 64653.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58236.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5872.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "037", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30956, "minimum": 22050, "maximum": 56093.1236, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30956.47, "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": 31266.07, "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": 48844.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48416.8 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 40243.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30956.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56093.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45196.45, "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": 43524.8, "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": 30956.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32813.89, "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": 30956.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30956.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30956.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49530.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30956.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30956.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53652.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30956.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48844.81 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 79229.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8599.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6176.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11526, "minimum": 5400, "maximum": 20885.9274, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 11526.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11641.77, "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": 16740.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16365.56 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14984.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11526.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20885.93, "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": 16828.62, "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": 16206.19, "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": 11526.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12218.09, "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": 11526.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11526.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11526.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18442.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11526.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11526.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19275.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 11526.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16740.99 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6196.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15145.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTRAOCULAR PROCEDURES EXCEPT ORBIT", "code_information": [ { "code": "115", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14825, "minimum": 13740.8996, "maximum": 27414.4, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26864.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21645.49, "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": 20844.91, "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": 14825.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15715.24, "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": 14825.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14825.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14825.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23721.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14825.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14825.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27414.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14825.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22518.41 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14825.68, "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": 14973.96, "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": 22518.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22438.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19273.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14825.68, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 3", "code_information": [ { "code": "7703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5481.78, "maximum": 5865.5, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5865.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FRACTURES OF FEMUR WITH MCC", "code_information": [ { "code": "533", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15126, "minimum": 9521.6532, "maximum": 27409.7254, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15126.78, "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": 15278.07, "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": 22428.69 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23399.45 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19664.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15126.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27409.73, "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": 22085.1, "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": 21268.25, "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": 15126.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16034.41, "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": 15126.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15126.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15126.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24202.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15126.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15126.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19927.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15126.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22428.69 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15013.68, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7635, "minimum": 7635.13, "maximum": 13964.1464, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7635.13, "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": 7711.48, "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": 10994.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10681.36 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9925.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13834.86, "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": 11147.29, "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": 10734.99, "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": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8093.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 8550, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 4500, "count": "1 through 10" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12216.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9041.99 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7635.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10994.46 } ] } ] }, { "description": "FRACTURES OF FEMUR WITHOUT MCC", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8135, "minimum": 6112.76, "maximum": 15142.984, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8135.43, "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": 8216.78, "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": 11972.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11617.97 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10576.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14741.4, "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": 11877.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 11438.41, "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": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8623.56, "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": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13016.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6112.76 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8135.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11972.56 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5804.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7421.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FRACTURES OF HIP AND PELVIS WITH MCC", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12504, "minimum": 9539.3712, "maximum": 22657.4473, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 12504.11, "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": 12629.14, "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": 19560.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18598.79 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16255.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12504.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22657.45, "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": 18256, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 17580.78, "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": 12504.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13254.35, "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": 12504.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12504.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12504.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20006.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12504.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12504.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17379.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 12504.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19560.57 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5169.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5081.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6606.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY", "code_information": [ { "code": "934", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21028, "minimum": 4285.52, "maximum": 38103.6239, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 21028.49, "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": 21238.79, "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": 31561.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30013.08 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 27337.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21028.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38103.62, "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": 30701.6, "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": 29566.06, "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": 21028.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22290.21, "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": 21028.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21028.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33645.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4285.52 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31561.08 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6839.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8995.05, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3624.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 195579, "minimum": 108450, "maximum": 354389.4742, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 195579.18, "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": 197534.79, "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": 315222.49 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 305800.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 254252.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 195579.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 354389.47, "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": 285545.6, "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": 274984.33, "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": 195579, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 207313.74, "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": 195579, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 195579.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 195579, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 312926.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 195579, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 195579.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 304395 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 195579, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 315222.49 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH CC", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9738, "minimum": 9738.22, "maximum": 17645.6546, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 9738.22, "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": 9835.6, "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": 14500.92 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14110.81 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12659.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17645.65, "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": 14217.8, "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": 13691.94, "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": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10322.51, "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": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15581.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10297 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 9738.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14500.92 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16395.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21026.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14184.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17894, "minimum": 17894.5, "maximum": 32424.834, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17894.5, "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": 18073.45, "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": 25813.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24772.09 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23262.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32424.83, "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": 26125.97, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "case rate", "standard_charge_dollar": 25159.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18968.17, "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": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28631.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22409.5 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17894.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25813.07 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19910.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7963.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7788, "minimum": 6063.32, "maximum": 55532.9368, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7788.43, "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": 7866.31, "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": 11453.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10913.72 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10124.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14112.64, "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": 11371.11, "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": 10950.53, "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": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8255.74, "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": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12461.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6063.32 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7788.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11453.36 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4367.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11897.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26664.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5578.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15076.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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 VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 36.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.53 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.66 } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE, 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": 8956, "minimum": 8659.35, "maximum": 18233.0032, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9045.66, "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": 13146.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12845.74 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11642.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16228.45, "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": 13075.91, "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": 12592.28, "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": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9493.47, "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": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14329.76, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8659.35 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8956.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13146.28 } ] } ] }, { "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": 13814, "minimum": 10577.646, "maximum": 25032.7438, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 13814.98, "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": 13953.15, "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": 21525.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21811.66 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17959.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13814.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25032.74, "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": 20169.87, "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": 19423.86, "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": 13815, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14643.9, "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": 13815, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13814.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13815, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22103.97, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13815, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13814.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15320.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 13815, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21525.6 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8992.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4623.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16133.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FRACTURES OF HIP AND PELVIS WITHOUT MCC", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8149, "minimum": 7503.21, "maximum": 14766.3504, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 8149.2, "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": 8230.69, "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": 11926.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11289.51 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10593.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14766.35, "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": 11897.83, "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": 11457.78, "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": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.15, "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": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13038.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7503.21 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11926.96 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29739.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7892, "minimum": 7592.69, "maximum": 14300.5939, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7892.16, "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": 7971.08, "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": 11476.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11267.99 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10259.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14300.59, "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": 11522.55, "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": 11096.38, "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": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8365.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Keenan", "plan_name": "Keenan", "methodology": "other", "standard_charge_dollar": 11250, "standard_charge_algorithm": "$4,500 per diem", "additional_payer_notes": "standard charge dollar calculated based on AMLOS Medicare", "median_amount": 4500, "10th_percentile": 4500, "90th_percentile": 13500, "count": "1 through 10" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12627.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7592.69 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7892.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11476.89 } ] } ] }, { "description": "FULL TERM NEONATE WITH MAJOR PROBLEMS", "code_information": [ { "code": "793", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 39011, "minimum": 14311.5, "maximum": 70689.3272, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 39011.77, "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": 39401.92, "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": 61340.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60374.7 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 50715.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 39011.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 70689.33, "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": 56957.18, "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": 54850.55, "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": 39011.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41352.51, "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": 39011.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 39011.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 39011.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 62418.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 39011.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 39011.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54502.7 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 39011.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61340.98 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITHOUT CCMCC", "code_information": [ { "code": "390", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5729, "minimum": 5039.02, "maximum": 10381.6547, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 5729.39, "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": 5786.68, "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": 8048.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8017.83 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7448.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10381.65, "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": 8364.91, "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": 8055.52, "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": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6073.15, "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": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9167.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5039.02 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 5729.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8048.38 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10494.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6774.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXC BACK TUM DEEP < 5 CM", "code_information": [ { "code": "21932", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13518.8, "discounted_cash": 3717, "minimum": 554.35, "maximum": 13518.75, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 593.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13518.75, "discounted_cash": 3717, "minimum": 554.35, "maximum": 13518.75, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 554.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 593.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19116.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9658.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55982.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "GASTROINTESTINAL HEMORRHAGE WITH MCC", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17516, "minimum": 17516.29, "maximum": 31739.5175, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 17516.29, "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": 17691.46, "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": 26742.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25678.58 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22771.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17516.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31739.52, "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": 25573.78, "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": 24627.9, "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": 17516.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18567.28, "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": 17516.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17516.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17516.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28026.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17516.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17516.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19945.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 17516.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26742.64 } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15548.49, "maximum": 16636.88, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16636.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "GASTROINTESTINAL HEMORRHAGE WITHOUT CCMCC", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6522, "minimum": 6522.53, "maximum": 11818.8244, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 6522.53, "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": 6587.76, "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": 9364.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9082.09 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8479.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11818.82, "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": 9522.89, "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": 9170.68, "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": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6913.88, "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": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10436.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8033 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 6522.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9364.78 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27879, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 346.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23304, "minimum": 18450, "maximum": 42227.156, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 23304.17, "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": 23537.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36010.34 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35657.12 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30295.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23304.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42227.16, "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": 34024.09, "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": 32765.66, "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": 23304.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24702.45, "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": 23304.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23304.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23304.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37286.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23304.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23304.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27985.4 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 23304.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36010.34 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15753.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "983", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16469, "minimum": 9000, "maximum": 40496.2608, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26351.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16469.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14952.2 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 16469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24536.39 }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 16469.79, "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": 16634.5, "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": 24536.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23453.95 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21410.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16469.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29843.26, "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": 24045.89, "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": 23156.52, "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": 16469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17457.99, "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": 16469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16469.79, "additional_payer_notes": "100.00% of Medicare 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24021.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6223.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4190.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5808.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6057.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5833.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6356.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18155.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46323.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52309.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 208263.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8689.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41925.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4440.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10299.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15437.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8500.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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 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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30186.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9542.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11339.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27562.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "FOOT PROCEDURES WITH MCC", "code_information": [ { "code": "503", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26357, "minimum": 26357.38, "maximum": 47759.5726, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 26357.38, "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": 26620.97, "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": 38927 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38466.94 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34264.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 26357.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47759.57, "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": 38481.77, "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": 37058.48, "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": 26357.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27938.84, "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": 26357.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26357.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26357.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 42171.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 26357.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26357.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34586.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 26357.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38927 } ] } ] }, { "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": 66579, "minimum": 38044.0896, "maximum": 120642.4164, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 66579.7, "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": 67245.5, "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": 98235.29 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99250.43 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 86553.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 120642.42, "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": 97206.36, "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": 93611.06, "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": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 70574.48, "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": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 106527.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 40505.3 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 66579.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98235.29 } ] } ] }, { "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": 30301, "minimum": 20512.8, "maximum": 54907.1334, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 30301.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30605.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46778.29 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46120.46 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 39392.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30301.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 54907.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44240.85, "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": 42604.54, "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": 30302, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32120.12, "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": 30302, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30301.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30302, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48483.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30302, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30301.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20512.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 30302, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46778.29 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12320.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": 7985, "minimum": 6799.15, "maximum": 14470.2696, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 7985.8, "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": 8065.66, "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": 11790.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11422.9 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10381.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14470.27, "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": 11659.27, "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": 11228.03, "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": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8464.95, "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": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12777.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6799.15 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 7985.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11790.18 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH MCC", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14292, "minimum": 14292.3, "maximum": 25897.702, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 14292.33, "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": 14435.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21619.74 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20847.8 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18579.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14292.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25897.7, "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": 20866.8, "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": 20095.02, "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": 14292.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15149.84, "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": 14292.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14292.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14292.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22867.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14292.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14292.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14732.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 14292.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21619.74 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5518.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7582.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": "Caloptima Medi-Cal IP", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10266.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "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": 15187, "minimum": 12075.4076, "maximum": 27519.5144, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 15187.37, "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": 15339.27, "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": 22144.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23250.28 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19743.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15187.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27519.51, "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": 22173.56, "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": 21353.44, "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": 15187.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16098.64, "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": 15187.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15187.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15187.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24299.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15187.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15187.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18295.9 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 15187.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22144.82 } ] } ] }, { "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": 10120, "minimum": 10120.1, "maximum": 37643.6628, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14996.59 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14938.41 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13156.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18337.62, "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": 14775.35, "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": 14228.86, "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": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10727.31, "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": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16192.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11466.1 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 10120.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14996.59 } ] } ] }, { "description": "HAND PROCEDURES FOR INJURIES", "code_information": [ { "code": "906", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18767, "minimum": 14400, "maximum": 45349.8116, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "case rate", "standard_charge_dollar": 18767.5, "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": 18955.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 32100.87 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26988.11 }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24397.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34006.71, "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": 27400.55, "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": 26387.11, "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": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19893.55, "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": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30028, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21919.8 }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "case rate", "standard_charge_dollar": 18767.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32100.87 } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.57 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 } ] } ] }, { "description": "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": 954.81, "10th_percentile": 954.81, "90th_percentile": 954.81, "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": 2239.88, "10th_percentile": 2239.88, "90th_percentile": 4214.73, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.07, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 445.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 429.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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" } ] } ] }, { "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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 353.07 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Allergen Spec Ige Qualit,Multi", "code_information": [ { "code": "86005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.25, "discounted_cash": 7, "minimum": 7.97, "maximum": 30.25, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.8 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10082.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13150.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12755.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13778.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1098.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1026.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9982.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13150.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 477.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 445.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholine Receptor Binding Antibody", "code_information": [ { "code": "86041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115, "discounted_cash": 18, "minimum": 18.4, "maximum": 115, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 243.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 227.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.4, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 109.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 110.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 66.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 78.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 117.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 79.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 62.61 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 48.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 45.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42.97, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 130.44, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 114.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 111.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 126.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 122.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 86.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 114.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3737.22, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3712.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 517.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.26, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 56.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 58.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 56.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.94 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.92, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Hep B Vac - G0010 - 77100010 - 77100010", "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 267.7, "discounted_cash": 59, "minimum": 59.92, "maximum": 267.7, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 159.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "106.00% 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.6 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.42 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 90.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 763, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 658.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 132.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 1279.4, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.16 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amputation Toe Interphalangeal Joint", "code_information": [ { "code": "28825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4735.67, "discounted_cash": 4187, "minimum": 290.51, "maximum": 4735.67, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 310.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 290.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4735.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.51 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.11 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 52.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.77, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 145.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 309.12 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 288.9 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 102.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3623.69, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 133.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8505.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 303, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 383.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 420, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 438 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 421.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 256.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 395.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 450, "additional_payer_notes": "150.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "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 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 493.17 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 460.91 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholn Rcptr Blckg Antb", "code_information": [ { "code": "86042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115, "discounted_cash": 18, "minimum": 18.4, "maximum": 115, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 488.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 329.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 416.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 456.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 475.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 458.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 429.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 325.8, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Acetylcholn Rcptr Modlg Antb", "code_information": [ { "code": "86043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.31, "discounted_cash": 12, "minimum": 12.05, "maximum": 75.31, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.99, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 122.82, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 82.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 107.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 104.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 119.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 115.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 81.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 107.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 67.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 65.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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 VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.45 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 34.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Influenza Virus Vac - G0008 - 77100008 - 77100008", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 308.79, "discounted_cash": 59, "minimum": 25, "maximum": 308.79, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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 VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 33.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.48 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.68 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.17, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 49.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 47.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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 VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.64, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.04 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.49 } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1418.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1381.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1329.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 159.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 148.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 311.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Pulmon Bilat Select", "code_information": [ { "code": "75743", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17368.6, "discounted_cash": 4041, "minimum": 104.21, "maximum": 17368.6, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 846.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 33.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 846.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 63.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 58.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 61.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 59.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 954.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 101.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.69, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2078.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2881.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3004.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2893.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 93.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 36.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 485.63, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 326.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 426.49, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 413.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 453.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 472.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 455.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 426.49, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.1, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.32 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 189.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.26 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.95 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Ashkenazi Jewish Assoc Dsrdrs Gen Seq Anal 9 Gen", "code_information": [ { "code": "81412", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2100, "discounted_cash": 2448, "minimum": 630, "maximum": 2100, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2100 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2100, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.91 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.48 } ] } ] }, { "description": "Hc 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": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.93, "additional_payer_notes": "140.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc App Skn Sub 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 184.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1926.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": 171.08, "10th_percentile": 171.08, "90th_percentile": 171.08, "count": "1 through 10" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 90.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Application Of Finger Splint", "code_information": [ { "code": "29131", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 261.85, "discounted_cash": 75, "minimum": 48.07, "maximum": 261.85, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 261.85, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.83 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 1116.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 126.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.55 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 1062.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 76.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 65.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 72.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 1524.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 629.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 172.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.77, "additional_payer_notes": "146.00% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 96.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 90.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 90.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 84.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay For Phencyclidine", "code_information": [ { "code": "83992", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.6, "discounted_cash": 20, "minimum": 20, "maximum": 142.6, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Rigid Leg Cast", "code_information": [ { "code": "29445", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 982.9, "discounted_cash": 357, "minimum": 195.98, "maximum": 982.9, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 209.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 2D Tte W Or W/O Fol W/Con Complete - C8923 - 48300011", "code_information": [ { "code": "C8923", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5670.26, "discounted_cash": 1003, "minimum": 1003.31, "maximum": 5670.26, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1464.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1410.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.11 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.19 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.76, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 57.97, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 58.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1741.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 688.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 645.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 247.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 231.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.62, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 54.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 54.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.43, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Pneumococcal Vac - G0009 - 77100009 - 77100009", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 334.63, "discounted_cash": 59, "minimum": 59.92, "maximum": 334.63, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 84.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amitriptyline - G0480 - 30100408", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 219.24, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc 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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 414.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 279.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 386.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 403.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 388.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lap Enzyme", "code_information": [ { "code": "83670", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 9, "minimum": 9.35, "maximum": 66, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "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": 9.91, "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": 12.92, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.35 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 688.14, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 645.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.34, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 420.39, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 409.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 394.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.34, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 99.1, "10th_percentile": 99.1, "90th_percentile": 99.1, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.08, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1355.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 64.57 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 } ] } ] }, { "description": "Hc Amniocentesis,Diagnostic", "code_information": [ { "code": "59000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1040.5, "discounted_cash": 1178, "minimum": 82.13, "maximum": 1040.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1040.5, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.84 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.25, "additional_payer_notes": "106.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 126.24, "10th_percentile": 126.24, "90th_percentile": 126.24, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrocentesis Aspir&/Inj Interm Jt/Burs W/Us", "code_information": [ { "code": "20606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1529.54, "discounted_cash": 903, "minimum": 45.05, "maximum": 1529.54, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 912.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1190.13, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1154.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1264.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1319.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1270.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1190.13, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6281.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 363.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Metanephrines", "code_information": [ { "code": "83835", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105.88, "discounted_cash": 16, "minimum": 16.94, "maximum": 105.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "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": 22.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.32, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 40.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cryofibrinogen", "code_information": [ { "code": "82585", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 128.48, "discounted_cash": 14, "minimum": 10.72, "maximum": 128.48, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.72 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.72 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.47 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.72 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 10.72 }, { "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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 57.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Nickel", "code_information": [ { "code": "83885", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 266.72, "discounted_cash": 24, "minimum": 24.51, "maximum": 266.72, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.77, "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": 24.76, "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": 32.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 34.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Erythropoietin", "code_information": [ { "code": "82668", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 234.88, "discounted_cash": 18, "minimum": 18.79, "maximum": 234.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.19, "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": 18.98, "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": 24.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.75, "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10682.67, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10397.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10013.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 93.88 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.74 } ] } ] }, { "description": "Hc Assay Of Estrogen", "code_information": [ { "code": "82672", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 217, "discounted_cash": 21, "minimum": 21.7, "maximum": 217, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.92, "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": 28.59, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.59, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 17-(17-Ks)Ketosteroids", "code_information": [ { "code": "83586", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.65, "discounted_cash": 12, "minimum": 7.095, "maximum": 23.65, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.2, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 153.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.37 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.32, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": 171.08, "10th_percentile": 171.08, "90th_percentile": 171.08, "count": "1 through 10" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Ethchlorvynol - G0480 - 30100071", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 211.68, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Pregnanediol", "code_information": [ { "code": "84135", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.5, "discounted_cash": 21, "minimum": 12.15, "maximum": 40.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.91, "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": 21.48, "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": 28.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.02, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 82.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 90.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.24 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.97 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.88, "additional_payer_notes": "100.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6061.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5900.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5681.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 106.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Prostaglandin", "code_information": [ { "code": "84150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 271.68, "discounted_cash": 41, "minimum": 31.18, "maximum": 271.68, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.66, "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": 42.19, "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": "fee schedule", "standard_charge_dollar": 55.03, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 31.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 58.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 58.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 44.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.03, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 44.3, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 41.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.9, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.95 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 165.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 154.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Selenium", "code_information": [ { "code": "84255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.8, "discounted_cash": 25, "minimum": 11.04, "maximum": 36.8, "payers_information": [ { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.8, "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": 25.79, "additional_payer_notes": "101.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.93 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 39.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.81 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.6 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.32 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.84 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.26, "additional_payer_notes": "127.78% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Thyroglobulin", "code_information": [ { "code": "84432", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80.3, "discounted_cash": 16, "minimum": 16.06, "maximum": 80.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "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": 16.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.16, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 64.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.5 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 51.87 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.17 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.37 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Total Estradiol", "code_information": [ { "code": "82670", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83.82, "discounted_cash": 27, "minimum": 25.146, "maximum": 83.82, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.91, "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": 28.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.81, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.7, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 39.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.81, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "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 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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aortic Dys/Dilat Genom Seq Ana", "code_information": [ { "code": "81410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2750, "discounted_cash": 504, "minimum": 504, "maximum": 2750, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 756, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 663.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 644.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 705.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 735.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 708.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 504, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 663.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Transferrin", "code_information": [ { "code": "84466", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.8, "discounted_cash": 12, "minimum": 12.63, "maximum": 63.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.14, "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": 12.89, "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": "fee schedule", "standard_charge_dollar": 16.81, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.86, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.81, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 1398.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 186.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 174.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Troponin, Quant", "code_information": [ { "code": "84484", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 384.96, "discounted_cash": 12, "minimum": 9.72, "maximum": 384.96, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.71, "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": 12.59, "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": 16.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 111.76, "10th_percentile": 111.76, "90th_percentile": 151.42, "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": 18.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.43, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Phenothiazine - G0480 - 30100385", "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 954.21, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 303.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 292.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Alkaloids - G0480 - 30100213", "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.52 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.52 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.52 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 658.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 361.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 457.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 501.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 522.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 503.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 357.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 471.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Creatinine", "code_information": [ { "code": "82570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 203.43, "discounted_cash": 5, "minimum": 5.18, "maximum": 203.43, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.28 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 5.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.06 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.01 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Creatinine", "code_information": [ { "code": "82565", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 192.48, "discounted_cash": 5, "minimum": 4.95, "maximum": 192.48, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.17, "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": 6.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Phosphorus", "code_information": [ { "code": "84105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 122, "discounted_cash": 5, "minimum": 5.3, "maximum": 122, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.67, "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": 5.84, "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": 7.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Prealbumin", "code_information": [ { "code": "84134", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 315.05, "discounted_cash": 14, "minimum": 14.31, "maximum": 315.05, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.89, "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": 14.74, "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": 19.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.22, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.38, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 53.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Sodium", "code_information": [ { "code": "84300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 189.11, "discounted_cash": 5, "minimum": 4.96, "maximum": 189.11, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.59, "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": 5.11, "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": 6.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.96 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.96 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Progesterone", "code_information": [ { "code": "84144", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 376, "discounted_cash": 20, "minimum": 20.86, "maximum": 376, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.29, "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": 21.07, "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": 27.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Digoxin", "code_information": [ { "code": "80162", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 450.9, "discounted_cash": 13, "minimum": 13.28, "maximum": 450.9, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.49, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.49, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Vma", "code_information": [ { "code": "84585", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 214.06, "discounted_cash": 15, "minimum": 15.5, "maximum": 214.06, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.25, "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": 15.66, "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": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.81 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.81 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.07 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.2, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rh (D)", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 297.79, "discounted_cash": 47, "minimum": 2.82, "maximum": 297.79, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vancomycin", "code_information": [ { "code": "80202", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 489.62, "discounted_cash": 13, "minimum": 13.54, "maximum": 489.62, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "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": 13.68, "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": 17.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.84, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "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": 320.67, "10th_percentile": 320.67, "90th_percentile": 320.67, "count": "1 through 10" }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vitamin A", "code_information": [ { "code": "84590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 145.13, "discounted_cash": 11, "minimum": 11.61, "maximum": 145.13, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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": 11.73, "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": 15.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Renin", "code_information": [ { "code": "84244", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.95, "discounted_cash": 21, "minimum": 21.99, "maximum": 109.95, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 22.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.99, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.31, "additional_payer_notes": "106.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vitamin B-1", "code_information": [ { "code": "84425", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.69, "discounted_cash": 21, "minimum": 21.23, "maximum": 132.69, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "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": 21.44, "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": 27.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.65 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.65 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.97, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.61, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.49 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.61 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 100.04, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 67.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 93.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 97.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 93.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Other Fluid Chlorides", "code_information": [ { "code": "82438", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15, "discounted_cash": 5, "minimum": 4.5, "maximum": 15, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.5, "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": 5.05, "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": 6.59, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 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": 4.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Salicylate - G0480 - 30100044", "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": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.5, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Phosphohexose Enzymes", "code_information": [ { "code": "84087", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 228, "discounted_cash": 10, "minimum": 10.53, "maximum": 228, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "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": 10.84, "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": 14.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Serum Potassium", "code_information": [ { "code": "84132", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 265.23, "discounted_cash": 4, "minimum": 3.95, "maximum": 265.23, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.14, "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": 4.81, "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": 6.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment,Serum Inhib", "code_information": [ { "code": "86977", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.35, "discounted_cash": 218, "minimum": 11.385, "maximum": 380.35, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Rbc Glutathione", "code_information": [ { "code": "82979", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 112.56, "discounted_cash": 9, "minimum": 8.61, "maximum": 112.56, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.16, "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": 9.53, "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": 12.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "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": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.44, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Pretreatment,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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 577.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 571.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 625.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Synovial Fluid Mucin", "code_information": [ { "code": "83872", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 111.72, "discounted_cash": 5, "minimum": 5.86, "maximum": 111.72, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.92, "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": 7.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.49, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Silica", "code_information": [ { "code": "84285", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 256.32, "discounted_cash": 25, "minimum": 24.01, "maximum": 256.32, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.82, "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": 25.46, "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": 33.21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.21, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.17 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.83 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 73.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Vit D, 25-Hydroxy W Fractions", "code_information": [ { "code": "82306", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 344.92, "discounted_cash": 29, "minimum": 23.78, "maximum": 344.92, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 44.4, "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": 29.9, "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": 38.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 43.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 41.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.99, "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": "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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.7 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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" } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Free Hydroxyproline", "code_information": [ { "code": "83500", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.92, "discounted_cash": 22, "minimum": 10.776, "maximum": 35.92, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.98, "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": 22.88, "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": 29.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.84, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.43 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Ketogenic Steroids", "code_information": [ { "code": "83582", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 192.8, "discounted_cash": 15, "minimum": 14.46, "maximum": 192.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.21, "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": 15.62, "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": 20.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.38, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 651.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 627.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Three Catecholamines", "code_information": [ { "code": "82384", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 225.75, "discounted_cash": 25, "minimum": 25.25, "maximum": 225.75, "payers_information": [ { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.88, "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": 25.5, "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": 33.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 25.76 } ] } ] }, { "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.7 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.87 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Myoglobin", "code_information": [ { "code": "83874", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 161.5, "discounted_cash": 12, "minimum": 12.92, "maximum": 161.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "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": 13.05, "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": 17.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.02, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assayof Estrogen Receptor", "code_information": [ { "code": "84233", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 87, "minimum": 71.13, "maximum": 286, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 131.82, "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": 88.76, "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": 115.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 71.13 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 71.13 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 112.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 123.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 128.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 123.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 93.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 71.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 71.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 87.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 115.77, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.17, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Neonatal Thyroxine", "code_information": [ { "code": "84437", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 114.53, "discounted_cash": 6, "minimum": 6.47, "maximum": 114.53, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 6.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 589.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.99 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Nos Vitamin", "code_information": [ { "code": "84591", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 157.9, "discounted_cash": 17, "minimum": 10.1, "maximum": 157.9, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.59, "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": 17.23, "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": 22.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.47, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 60.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "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 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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Audiometry Air & Bone", "code_information": [ { "code": "92553", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.75, "discounted_cash": 164, "minimum": 29.26, "maximum": 589.75, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 247.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 231.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 31.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 29.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.36 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.94 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Oxalate", "code_information": [ { "code": "83945", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.52, "discounted_cash": 14, "minimum": 5.256, "maximum": 17.52, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.52, "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": 14.59, "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": 17.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.52, "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": "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.06, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "Hc B Cells, Total Count", "code_information": [ { "code": "86355", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.34, "discounted_cash": 37, "minimum": 15.402, "maximum": 51.34, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 51.34, "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": 38.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 51.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 51.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 26.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Triglycerides", "code_information": [ { "code": "84478", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 265.59, "discounted_cash": 5, "minimum": 5.74, "maximum": 265.59, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.8, "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": 7.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.76 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.76 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.56, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Progesterone 17-D", "code_information": [ { "code": "83498", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.85, "discounted_cash": 27, "minimum": 27.17, "maximum": 135.85, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.76, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.44, "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": 35.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 27.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 38.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.79, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.27 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Bacterium, Antibody", "code_information": [ { "code": "86609", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 77.28, "discounted_cash": 12, "minimum": 12.88, "maximum": 77.28, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.32, "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": 13.01, "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": 16.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.97, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Albumin", "code_information": [ { "code": "82042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 144.16, "discounted_cash": 7, "minimum": 3.25, "maximum": 144.16, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.67, "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": 7.86, "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": 10.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Proinsulin", "code_information": [ { "code": "84206", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 333.63, "discounted_cash": 26, "minimum": 22.25, "maximum": 333.63, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.04, "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": 26.96, "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": 35.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 22.25 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.25 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 37.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.69, "additional_payer_notes": "100.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.7, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Balloon Dilat Biliary Duct/Ampulla Prq Each Duct", "code_information": [ { "code": "47542", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4345, "minimum": 469.47, "maximum": 4345, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 469.47 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 469.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 502.33 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 469.47 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 469.47 } ] } ] }, { "description": "Hc Assay Of Urobilinogen Urine Quan Tmd Spec", "code_information": [ { "code": "84580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.66, "discounted_cash": 9, "minimum": 2.898, "maximum": 9.66, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "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": 9.65, "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": 9.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Prolactin", "code_information": [ { "code": "84146", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 145.35, "discounted_cash": 19, "minimum": 19.38, "maximum": 145.35, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.07, "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": 19.57, "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": 25.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.53, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 61.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 57.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 57.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Basic Metabolic Panel Calcium Total", "code_information": [ { "code": "80048", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 550.61, "discounted_cash": 8, "minimum": 8.34, "maximum": 550.61, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.69, "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": 8.54, "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": 11.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 51, "standard_charge_algorithm": "Not To Exceed $4132", "additional_payer_notes": "Not to exceed limits in contract for this procedure", "median_amount": 216.57, "10th_percentile": 159.84, "90th_percentile": 280.82, "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": 12.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.97, "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": 5.82, "10th_percentile": 5.82, "90th_percentile": 5.82, "count": "1 through 10" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Valproic Acid, Free", "code_information": [ { "code": "80165", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 404.61, "discounted_cash": 13, "minimum": 12.04, "maximum": 404.61, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "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": 13.68, "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": 17.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 12.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.84, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Pyruvate", "code_information": [ { "code": "84210", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.77, "discounted_cash": 14, "minimum": 4.431, "maximum": 14.77, "payers_information": [ { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.77, "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": 14.62, "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": 14.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.29 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.29 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.48, "additional_payer_notes": "100.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bcr/Abl1 Gene Major Bp", "code_information": [ { "code": "81206", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 868.64, "discounted_cash": 163, "minimum": 86.7, "maximum": 868.64, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 245.94, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 165.6, "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": 215.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 86.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 209.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 229.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 239.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 230.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 163.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 215.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vitamin E", "code_information": [ { "code": "84446", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 141.8, "discounted_cash": 14, "minimum": 13.77, "maximum": 141.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.77 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.77 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.77 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 13.77 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Pyruvate Kinase", "code_information": [ { "code": "84220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 203.38, "discounted_cash": 9, "minimum": 9.44, "maximum": 203.38, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.16, "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": 9.53, "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": 12.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.44, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bile Acids, Total", "code_information": [ { "code": "82239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 184.69, "discounted_cash": 17, "minimum": 16.71, "maximum": 184.69, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.29, "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": 22.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.97, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.55, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Zinc", "code_information": [ { "code": "84630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.19, "discounted_cash": 11, "minimum": 11.39, "maximum": 71.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.09, "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": 11.5, "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": 15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Rbc Galactokinase", "code_information": [ { "code": "82759", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 263.16, "discounted_cash": 21, "minimum": 21.48, "maximum": 263.16, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.41 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 21.88 }, { "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 HealthPlan", "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 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy Of Floor Of Mouth", "code_information": [ { "code": "41108", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6877.5, "discounted_cash": 2113, "minimum": 139.38, "maximum": 6877.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 139.38 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.38 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 149.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 139.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 139.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Phosphatase Acid Prostatic", "code_information": [ { "code": "84066", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.15, "discounted_cash": 9, "minimum": 3.945, "maximum": 13.15, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.15, "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": 9.76, "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": 12.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.86 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.86 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.34, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Serum Sodium", "code_information": [ { "code": "84295", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 159.01, "discounted_cash": 4, "minimum": 4.03, "maximum": 159.01, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.22, "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": 4.86, "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": 6.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.03 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.03 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.34, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy Of Soft Tissues", "code_information": [ { "code": "27040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8742.98, "discounted_cash": 2113, "minimum": 195.98, "maximum": 8742.98, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 209.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 195.98 } ] } ] }, { "description": "Hc Assay Phosphatase Acid, Total", "code_information": [ { "code": "84060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.95, "discounted_cash": 7, "minimum": 4.185, "maximum": 13.95, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "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": 7.72, "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": 10.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.06, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Sex Hormone Binding Globulin", "code_information": [ { "code": "84270", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 134.4, "discounted_cash": 21, "minimum": 21.48, "maximum": 134.4, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.6, "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": 21.95, "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": 28.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.63, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy Soft Tissue Back,Deep", "code_information": [ { "code": "21925", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3546.2, "discounted_cash": 2113, "minimum": 386.1, "maximum": 3546.2, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 386.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 413.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 386.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Sngl Organic Acid, Quantitative", "code_information": [ { "code": "83921", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.56, "discounted_cash": 21, "minimum": 11.74, "maximum": 132.56, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.82, "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": 21.42, "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": 27.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Somatomedin", "code_information": [ { "code": "84305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 182.8, "discounted_cash": 21, "minimum": 21.1, "maximum": 182.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.89, "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": 21.47, "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": 28.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.01, "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": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Bld Clot Factor Viii, Vw Fc Antigen", "code_information": [ { "code": "85246", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286.75, "discounted_cash": 22, "minimum": 22.94, "maximum": 286.75, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.17, "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": 30.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Test For Blood Fecal", "code_information": [ { "code": "82274", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 194.85, "discounted_cash": 15, "minimum": 11.31, "maximum": 194.85, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.88, "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": 16.08, "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": 20.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.31 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.31 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.34, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.31 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.31 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.97, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Somatostatin", "code_information": [ { "code": "84307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 223.92, "discounted_cash": 18, "minimum": 18.28, "maximum": 223.92, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.42, "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": 18.46, "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": 24.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.65 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.65 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.08, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bld Clot Factor Viii, Vw Fc, Ristocetin Cofactr", "code_information": [ { "code": "85245", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 114.7, "discounted_cash": 22, "minimum": 22.94, "maximum": 114.7, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34.41, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.17, "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": 30.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 32.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Tyrosine", "code_information": [ { "code": "84510", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.16, "discounted_cash": 10, "minimum": 4.248, "maximum": 14.16, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.16, "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": 10.74, "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": 14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "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": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Transcortin", "code_information": [ { "code": "84449", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 205.74, "discounted_cash": 18, "minimum": 18, "maximum": 205.74, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 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": 18.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 37.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor Vii Test", "code_information": [ { "code": "85230", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 89.5, "discounted_cash": 17, "minimum": 17.9, "maximum": 89.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.85, "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": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 18.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Urea Nitrogen, Quan", "code_information": [ { "code": "84520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.88, "discounted_cash": 3, "minimum": 3.61, "maximum": 196.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.93, "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": 3.99, "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": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Troponin Qual", "code_information": [ { "code": "84512", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.28, "discounted_cash": 10, "minimum": 9.26, "maximum": 115.28, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "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": 10.19, "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": "fee schedule", "standard_charge_dollar": 13.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium, Total", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 186.88, "discounted_cash": 5, "minimum": 4.7, "maximum": 186.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.74, "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": 5.21, "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": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor Viii Test, One Stage", "code_information": [ { "code": "85240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 111.88, "discounted_cash": 17, "minimum": 17.9, "maximum": 111.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.85, "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": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 18.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Vit D, 1,25-Dihydroxy W Fractions", "code_information": [ { "code": "82652", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.55, "discounted_cash": 38, "minimum": 38.07, "maximum": 293.55, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.75, "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": 38.89, "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": "fee schedule", "standard_charge_dollar": 50.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 38.07 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.07 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.2, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 53.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 54.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.07 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.07 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Uric Acid, Blood", "code_information": [ { "code": "84550", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 209.97, "discounted_cash": 4, "minimum": 4.52, "maximum": 209.97, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.79, "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": 3.21, "10th_percentile": 3.21, "90th_percentile": 3.21, "count": "1 through 10" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.78, "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": 4.57, "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": 5.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.36 } ] } ] }, { "description": "Hc Assay Of Citrate", "code_information": [ { "code": "82507", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.24, "discounted_cash": 27, "minimum": 27.8, "maximum": 311.24, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.7, "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": 28.08, "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": 36.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 39.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.62, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor Xii Test", "code_information": [ { "code": "85280", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.75, "discounted_cash": 19, "minimum": 19.35, "maximum": 93.75, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.54, "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": 25.49, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.74 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.74 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.49, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Aminolevulinic Acid", "code_information": [ { "code": "82135", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.04, "discounted_cash": 16, "minimum": 8.112, "maximum": 27.04, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "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": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Uric Acid, Blood, Other Source", "code_information": [ { "code": "84560", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 203.85, "discounted_cash": 5, "minimum": 4.84, "maximum": 203.85, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.62, "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": 5.13, "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": 6.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.49, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.69, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cocaine - G0480 - 30100327", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 185.58, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Retraction", "code_information": [ { "code": "85170", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.5, "discounted_cash": 16, "minimum": 4.52, "maximum": 132.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.45, "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": 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": 21.47, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.52 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.52 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.52 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.52 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.47, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Urine Catecholamines", "code_information": [ { "code": "82382", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.29, "discounted_cash": 27, "minimum": 7.887, "maximum": 26.29, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "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": 26.29, "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": 26.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.29, "additional_payer_notes": "106.00% 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Culture For Bacteria", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 333.46, "discounted_cash": 10, "minimum": 10.3, "maximum": 333.46, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "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": 10.42, "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": 13.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Chloride", "code_information": [ { "code": "82436", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 162.12, "discounted_cash": 5, "minimum": 5.04, "maximum": 162.12, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.63, "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": 5.81, "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": 7.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cryoglobulin", "code_information": [ { "code": "82595", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.35, "discounted_cash": 6, "minimum": 6.1, "maximum": 32.35, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 6.1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Folic Acid Serum", "code_information": [ { "code": "82746", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 363.78, "discounted_cash": 14, "minimum": 14.7, "maximum": 363.78, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.05, "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": 14.85, "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": 19.37, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.37, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Auditory Function 60 Min", "code_information": [ { "code": "92620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 589.75, "discounted_cash": 164, "minimum": 40.75, "maximum": 589.75, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 247.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 166.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 40.75 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.75 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 231.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 40.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Urine Sulfate", "code_information": [ { "code": "84392", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 96.9, "discounted_cash": 5, "minimum": 5.04, "maximum": 96.9, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "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": 5.54, "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": 7.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.04 } ] } ] }, { "description": "Hc Assay Of Cyclosporine", "code_information": [ { "code": "80158", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280, "discounted_cash": 18, "minimum": 18.05, "maximum": 280, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.08, "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": 18.23, "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": 23.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.41 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.41 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Fungus Culture", "code_information": [ { "code": "87103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 258, "discounted_cash": 20, "minimum": 9.19, "maximum": 258, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.69, "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": 20.66, "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": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Autologous Blood Process", "code_information": [ { "code": "86890", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 535, "discounted_cash": 218, "minimum": 160.5, "maximum": 535, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Valproic Acid, Total", "code_information": [ { "code": "80164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 412, "discounted_cash": 13, "minimum": 13.54, "maximum": 412, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.31, "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": 13.68, "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": 17.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.84, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Gases: Ph, Po2 & Pco2 W O2 Satu", "code_information": [ { "code": "82805", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 659.47, "discounted_cash": 78, "minimum": 27.88, "maximum": 659.47, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 118.16, "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": 79.56, "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": 103.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 100.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 110.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 110.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 103.77, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc B-12 Binding Capacity", "code_information": [ { "code": "82608", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.48, "discounted_cash": 14, "minimum": 5.844, "maximum": 19.48, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.48, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 14.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vasopressin", "code_information": [ { "code": "84588", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.19, "discounted_cash": 33, "minimum": 13.857, "maximum": 46.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 46.19, "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": 34.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 34.62 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.62 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 43.37, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 46.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 46.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 34.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 34.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 99.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.97 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.39 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Blood Methemoglobin, Quant", "code_information": [ { "code": "83050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.5, "discounted_cash": 8, "minimum": 6.15, "maximum": 20.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.3, "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": 8.28, "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": 10.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.28 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bartonella Dna Quant", "code_information": [ { "code": "87472", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 349.74, "discounted_cash": 42, "minimum": 42.84, "maximum": 349.74, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.26, "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": 43.27, "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": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 60.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vip", "code_information": [ { "code": "84586", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.6, "discounted_cash": 35, "minimum": 15.18, "maximum": 50.6, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.6, "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": 35.68, "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": 46.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 49.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 49.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.54, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Platelet Aggregation", "code_information": [ { "code": "85576", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 414.69, "discounted_cash": 24, "minimum": 13.66, "maximum": 414.69, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.37, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.16, "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": 32.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 34.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Basic Metabolic Panel Calcium Ionized", "code_information": [ { "code": "80047", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 393, "discounted_cash": 13, "minimum": 6.54, "maximum": 393, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "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": 13.87, "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": 18.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Vitamin B-2", "code_information": [ { "code": "84252", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 253, "discounted_cash": 20, "minimum": 20.24, "maximum": 253, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.36, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "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": 26.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.08 } ] } ] }, { "description": "Hc Assay Of Fluoride", "code_information": [ { "code": "82735", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 70, "discounted_cash": 18, "minimum": 18.54, "maximum": 70, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.81, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.73, "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": 24.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Smear,Micro Exam,Manual Diff Wbc", "code_information": [ { "code": "85007", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 140.44, "discounted_cash": 3, "minimum": 3.11, "maximum": 140.44, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.7, "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": 3.84, "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": 5.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.11 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.11 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.01, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biofeedback Train Any Meth", "code_information": [ { "code": "90901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 184, "discounted_cash": 17, "minimum": 17.24, "maximum": 184, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "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": 17.41, "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": 22.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Rbc Protoporphyrin", "code_information": [ { "code": "84202", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.52, "discounted_cash": 14, "minimum": 5.856, "maximum": 19.52, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.52, "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": 14.49, "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": "fee schedule", "standard_charge_dollar": 18.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.63 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.63 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.34, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.52 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.9, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Transfusion Service", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2643.77, "discounted_cash": 564, "minimum": 564.64, "maximum": 2643.77, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 846.96, "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": 570.29, "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": 743.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 790.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 824.37, "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": 793.88, "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": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 598.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 743.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy Forearm Soft Tissues,Superfic", "code_information": [ { "code": "25065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3345, "discounted_cash": 2113, "minimum": 111.08, "maximum": 3345, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 111.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 118.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 111.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 111.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Urine Urea-N", "code_information": [ { "code": "84540", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 208.75, "discounted_cash": 5, "minimum": 3.8, "maximum": 208.75, "payers_information": [ { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.34, "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": 5.62, "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": 7.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Flurazepam - G0480 - 30100014", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 242.46, "discounted_cash": 114, "minimum": 10.2, "maximum": 715.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Body Fluid Specific Gravity", "code_information": [ { "code": "84315", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.8, "discounted_cash": 3, "minimum": 3.01, "maximum": 32.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "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": 3.31, "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": 4.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 3.01 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.01 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy Soft Tissue Shoulder Deep", "code_information": [ { "code": "23066", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4140.8, "discounted_cash": 3717, "minimum": 267.54, "maximum": 4140.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "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": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 267.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 267.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "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": 4140.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 286.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 267.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 267.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4140.8, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Bld/Serum Cholesterol", "code_information": [ { "code": "82465", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116, "discounted_cash": 4, "minimum": 4.35, "maximum": 116, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "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": 4.39, "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": 5.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.08 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Bone Biopsy,Excisional Superf", "code_information": [ { "code": "20240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4988.06, "discounted_cash": 3717, "minimum": 181.57, "maximum": 4988.06, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4988.06, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4988.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4988.06, "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": 4988.06, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Biopsy, Nail Unit (Sep Proc)", "code_information": [ { "code": "11755", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2368, "discounted_cash": 906, "minimum": 88.65, "maximum": 2368, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 88.65 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.65 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 94.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 88.65 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 88.65 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay, Non-Endocrine Receptor", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 274.88, "discounted_cash": 36, "minimum": 36.57, "maximum": 274.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.86, "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": 36.94, "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": 48.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 53.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 51.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Fructose Semen", "code_information": [ { "code": "82757", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 263.16, "discounted_cash": 17, "minimum": 17.34, "maximum": 263.16, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.01, "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": 17.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.84, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bone Biopsy,Trocar/Needle Deep", "code_information": [ { "code": "20225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5378.88, "discounted_cash": 2113, "minimum": 213.61, "maximum": 5378.88, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 228.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 213.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 213.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor Ix Test", "code_information": [ { "code": "85250", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 117.19, "discounted_cash": 19, "minimum": 19.04, "maximum": 117.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.56, "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": 19.23, "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": 25.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Asstv Technol Assmt Dir Cntct W/Reprt Ea 15 Min", "code_information": [ { "code": "97755", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 284.73, "discounted_cash": 41, "minimum": 41.54, "maximum": 284.73, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.31, "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": 41.96, "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": 54.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 58.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 60.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 58.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 44.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of G6Pd Enzyme", "code_information": [ { "code": "82955", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 198.31, "discounted_cash": 9, "minimum": 9.7, "maximum": 198.31, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.8, "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": 12.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 9.89 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.89 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bowel Pouch Endo Eval Wash/Brush", "code_information": [ { "code": "44385", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3763.8, "discounted_cash": 1190, "minimum": 172.49, "maximum": 3763.8, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 172.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172.49 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 184.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 172.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 172.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor Viii Test, Related Antigen", "code_information": [ { "code": "85244", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 250.11, "discounted_cash": 20, "minimum": 20.42, "maximum": 250.11, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.63, "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": 20.62, "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": 26.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.09, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.83 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Gastrin", "code_information": [ { "code": "82941", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.9, "discounted_cash": 17, "minimum": 17.63, "maximum": 142.9, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.45, "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": 17.81, "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": 23.22, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Brca1 Brca2 Gene Analysis Full Sequence Analysis", "code_information": [ { "code": "81163", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2340, "discounted_cash": 468, "minimum": 374.4, "maximum": 2340, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 702, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 472.68, "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": 616.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 374.4 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.4 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 598.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 655.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 683.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 658.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 400.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 496.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 468, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 616.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Clot Factor X Test", "code_information": [ { "code": "85260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 117.19, "discounted_cash": 17, "minimum": 17.9, "maximum": 117.19, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.85, "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": 18.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 18.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Autoimmune Rheumatoid Arthr, 12 Biomark", "code_information": [ { "code": "81490", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2906.3, "discounted_cash": 840, "minimum": 840.65, "maximum": 2906.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1260.98, "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": 849.06, "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": 1107.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1074.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1176.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1227.35 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 1181.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 891.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 840.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1107.43, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "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 Commercial 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": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.45 }, { "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": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.92 }, { "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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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 HealthPlan", "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 Bronchoscopy Bronch Stent, Add-On", "code_information": [ { "code": "31637", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15332.4, "minimum": 52.49, "maximum": 15332.4, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 52.49 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 56.16 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.49 } ] } ] }, { "description": "Hc Blood Draw <3 Yrs, Skilled Phys, Fem/Jugular", "code_information": [ { "code": "36400", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 166, "minimum": 24.03, "maximum": 166, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.71 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.03 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.03 } ] } ] }, { "description": "Hc Bacteria Culture Screen", "code_information": [ { "code": "87081", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280.89, "discounted_cash": 6, "minimum": 6.52, "maximum": 280.89, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.95, "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": 6.7, "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": 8.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "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": 388.7, "10th_percentile": 84.27, "90th_percentile": 582.78, "count": "1 through 10" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.73, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Glutathione", "code_information": [ { "code": "82978", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 194, "discounted_cash": 15, "minimum": 14.54, "maximum": 194, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.18, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.6, "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": 20.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.54 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.54 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.56 } ] } ] }, { "description": "Hc Bronchoscopy Bronch Stent, Initial", "code_information": [ { "code": "31636", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15332.4, "discounted_cash": 9032, "minimum": 142.22, "maximum": 15332.4, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13548.89, "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": 9122.92, "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": 11899.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 142.22 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.22 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11542.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12645.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13187.58, "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": 12699.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 152.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9574.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.22 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.22 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11899.08, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Draw <3 Yrs, Skilled Phys, Other Vein", "code_information": [ { "code": "36406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 138, "minimum": 33.64, "maximum": 138, "payers_information": [ { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 33.64 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.64 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.99 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.64 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.64 } ] } ] }, { "description": "Hc Bactericidal Level Serum", "code_information": [ { "code": "87197", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 182.61, "discounted_cash": 15, "minimum": 15.02, "maximum": 182.61, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.53, "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": 15.17, "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": 19.79, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.79, "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": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bronchoscopy Diag W Lavage", "code_information": [ { "code": "31624", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11650.3, "discounted_cash": 2278, "minimum": 306, "maximum": 11650.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2300.8, "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": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3189.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3325.91, "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": 3202.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 327.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2414.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Smear Micro Exam W/O Manual Diff", "code_information": [ { "code": "85008", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.38, "discounted_cash": 3, "minimum": 1, "maximum": 64.38, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.15, "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": 3.46, "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": 4.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Balloon Dilat Ureteral Stricture W/Img Gdn Rs&I", "code_information": [ { "code": "50706", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4098, "minimum": 699.92, "maximum": 4098, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 699.92 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 699.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 748.91 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 699.92 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 699.92 } ] } ] }, { "description": "Hc Assay Of Homocystine", "code_information": [ { "code": "83090", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 428, "discounted_cash": 17, "minimum": 11.99, "maximum": 428, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "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": 18.1, "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": 23.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 11.99 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bronchoscopy Excis Tumor", "code_information": [ { "code": "31640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9959.6, "discounted_cash": 4771, "minimum": 302.26, "maximum": 9959.6, "payers_information": [ { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 302.26 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6097.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6680.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6966.78, "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": 6709.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5058.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 302.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 302.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6286.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7157.66, "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": 4819.49, "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": "fee schedule", "standard_charge_dollar": 6286.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 302.26 } ] } ] }, { "description": "Hc Blood Transfusion Reaction Interpretation", "code_information": [ { "code": "86078", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1006.09, "discounted_cash": 218, "minimum": 218.05, "maximum": 1006.09, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bartonella Dna Amp Probe", "code_information": [ { "code": "87471", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 334.32, "discounted_cash": 35, "minimum": 35.09, "maximum": 334.32, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52.64, "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": 35.44, "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": 46.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 35.79 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.79 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 44.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 49.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 51.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 49.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lactic Acid", "code_information": [ { "code": "83605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 384.96, "discounted_cash": 11, "minimum": 10.8, "maximum": 384.96, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.36, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.69, "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": 15.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bronchoscopy Removal Bronchial Valve Ea Addl", "code_information": [ { "code": "31649", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5187.5, "discounted_cash": 2278, "minimum": 61.8, "maximum": 5187.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3417.03, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2300.8, "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": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 61.8 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.8 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2910.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3189.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3325.91, "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": 3202.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 66.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2414.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2278.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3000.95, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bartonella, Antibody", "code_information": [ { "code": "86611", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40, "discounted_cash": 10, "minimum": 7.24, "maximum": 40, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution 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": 7.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Lidocaine", "code_information": [ { "code": "80176", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.99, "discounted_cash": 14, "minimum": 5.997, "maximum": 19.99, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.99, "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": 14.84, "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": 19.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 14.99 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.99 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bronchoscopy Revise Previous Stent", "code_information": [ { "code": "31638", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15332.4, "discounted_cash": 9032, "minimum": 158.23, "maximum": 15332.4, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13548.89, "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": 9122.92, "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": 11899.08, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 158.23 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 158.23 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11542.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12645.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13187.58, "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": 12699.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 169.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9574.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 158.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 158.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9032.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11899.08, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Blood Typing, Abo", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 779.5, "discounted_cash": 170, "minimum": 2.73, "maximum": 846.21, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 255.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CA FOUNDATION FOR MEDICAL CARE", "plan_name": "CA FOUNDATION FOR MEDICAL CARE Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 248.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 239.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bcr/Abl1 Gene Minor Bp", "code_information": [ { "code": "81207", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 985.5, "discounted_cash": 144, "minimum": 72.3, "maximum": 985.5, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 217.26, "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": 146.29, "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": 190.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 72.3 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.3 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 185.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 202.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 211.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 203.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 153.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 72.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 144.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 190.8, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Mercury", "code_information": [ { "code": "83825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 169.4, "discounted_cash": 16, "minimum": 16.2, "maximum": 169.4, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.39, "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": 16.42, "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": 21.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Caloptima", "plan_name": "Caloptima Medi-Cal IP", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "COUNTY OF ORANGE (MSN)", "plan_name": "COUNTY OF ORANGE (MSN) Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct health Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Service Tricare", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan", "plan_name": "Imperial Health plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Verda HealthPlan", "plan_name": "Verda HealthPlan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Bronchoscopy W Ebus Sampling 3/> Node", "code_information": [ { "code": "31653", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17840.3, "discounted_cash": 4771, "minimum": 878.26, "maximum": 17840.3, "payers_information": [ { "payer_name": "Blue Shield of VA", "plan_name": "Blue Shield of CA TriWest Healthcare VA", "methodology": "fee schedule", "standard_charge_dollar": 4771.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Commercial Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7157.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare"