{ "hospital_name": "Encino Hospital Medical Center", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "Encino Hospital Medical Center" ], "hospital_address": [ "16237 Ventura Boulevard Encino, CA 91436" ], "license_information": { "license_number": "262128507", "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": "EM V. Garcia" }, "type_2_npi": [ "1437322377", "1629242201", "1083888663" ], "standard_charge_information": [ { "description": "$ PRE TREATMNT RBC CHEM/DRG*LS", "code_information": [ { "code": "86970", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 139.5, "discounted_cash": 75, "minimum": 3.825, "maximum": 139.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 77.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.47, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 98.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ ABSC *ARC", "code_information": [ { "code": "86850", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 125.48, "discounted_cash": 66, "minimum": 2.98, "maximum": 443, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 93.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 86.1, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 70.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 86.98, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.46, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ ABID *ARC", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 592.26, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 598.3, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 574.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 467.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 574.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "$$ ABID-EACH RGT CELL *ARC", "code_information": [ { "code": "86885", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.14, "discounted_cash": 218, "minimum": 4.242, "maximum": 14.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.63 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "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": 14.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% 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": 5.84 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "127.78% 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": 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.14, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ ELUTION *ARC", "code_information": [ { "code": "86860", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.07, "discounted_cash": 218, "minimum": 17.4, "maximum": 102.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 34.34 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "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": 88.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "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": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "127.78% 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": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 88.07, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ DAT *ARC", "code_information": [ { "code": "86880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 139.5, "discounted_cash": 75, "minimum": 2.961, "maximum": 231.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 77.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.47, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 98.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ AG TYPING/PT", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19, "discounted_cash": 458, "minimum": 2.62, "maximum": 105.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ ABO *ARC", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.3, "discounted_cash": 170, "minimum": 2.541, "maximum": 161.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "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": 27.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "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": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "127.78% 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": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.3, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$Rhotherphenotype (Not ABO/D)", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16, "discounted_cash": 458, "minimum": 3.84, "maximum": 50.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16, "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": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "127.78% 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": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$ RBC PHENOTYPE(CcEc)*ARC", "code_information": [ { "code": "86906", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 65.41, "discounted_cash": 47, "minimum": 5.98, "maximum": 75.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 65.41, "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": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 65.41, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 65.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 65.41, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "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": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$PRETREATMENT RBC CHEM/DRUG*RC", "code_information": [ { "code": "86970", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.11, "discounted_cash": 75, "minimum": 3.825, "maximum": 139.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "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": 55.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.83 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "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": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "127.78% 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": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.11, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "$$RHOTHERPHENOTYPE *NOT ABO/D", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.84, "discounted_cash": 458, "minimum": 3.84, "maximum": 50.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "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": 45.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "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": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "127.78% 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": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 45.84, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "17-OH PROGESTERONE LCMS", "code_information": [ { "code": "83498", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10, "discounted_cash": 27, "minimum": 3, "maximum": 10, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "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 Medi-Cal IPA", "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": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "0.9 % NS IRRIG SOLN 500ML", "code_information": [ { "code": "Z7610", "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": 52.69, "10th_percentile": 52.69, "90th_percentile": 52.69, "count": "1 through 10" } ] } ] }, { "description": "25 HYDROXYVIT D LCMS D2+D3 LC", "code_information": [ { "code": "82306", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28, "discounted_cash": 29, "minimum": 3.126, "maximum": 203.5, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28, "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": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% 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": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 28 } ] } ] }, { "description": "AB ID PANEL PANL 1$$ABID(LISS)", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 63, "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": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "127.78% 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": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABDCXRFB", "code_information": [ { "code": "76010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 371.8, "discounted_cash": 111, "minimum": 22.43, "maximum": 371.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 39.81 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "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": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 118.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "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": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 145.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% 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": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AB ID/EACH PANEL & MEDIA", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 89, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89, "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": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "127.78% 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": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "A1-ANTITRYPSIN SERUM LC", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.44, "discounted_cash": 13, "minimum": 1.578, "maximum": 61.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "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": 13.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABDOMEN ONE VW", "code_information": [ { "code": "74018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 311.5, "discounted_cash": 111, "minimum": 16.73, "maximum": 311.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "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": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 118.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 145.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABD APW/DCUB/UP", "code_information": [ { "code": "74021", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 567.2, "discounted_cash": 133, "minimum": 25.06, "maximum": 567.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.27 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "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": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 172.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 141.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 174.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AB RBC EA PNL", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 509.5, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 467.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "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": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 509.5, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "A-SUBUNIT, FREE LC 140269", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52.94, "discounted_cash": 17, "minimum": 2.355, "maximum": 365.32, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "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": 17.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.61, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.3, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.61, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7148.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 4", "code_information": [ { "code": "2514", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10145.16, "maximum": 10855.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10855.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AB SCREEN ABSCR $$ABSCR*LS", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 46, "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": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "127.78% 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": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "A4I RBC AG NEG 1 PER UNIT", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105.65, "discounted_cash": 458, "minimum": 2.62, "maximum": 105.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "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": 105.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 105.65, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABDOMINAL PARACENT W/O IMAG ER", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2294.3, "discounted_cash": 1160, "minimum": 58.45, "maximum": 2294.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1452.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1498.61, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1513.9, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1452.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 5515, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5515, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AB ID PANEL PANP $$ABID(PEG)LS", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 458, "minimum": 13.8, "maximum": 600, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52, "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": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% 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": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABO TYPING $$ABOTYPING*LS", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17, "discounted_cash": 170, "minimum": 2.541, "maximum": 161.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "127.78% 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": 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4007.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABO TYPE", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.55, "discounted_cash": 170, "minimum": 2.541, "maximum": 161.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "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": 31.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "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": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "127.78% 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": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.55, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4247.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACETAMNOPHN QNT - G0480 - 4102003", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 319.9, "discounted_cash": 114, "minimum": 1, "maximum": 1176.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 116.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.21, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.73, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 149.24, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.21, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18906.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY", "code_information": [ { "code": "770", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9731, "minimum": 9450, "maximum": 17634.1303, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15351.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9926.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11327.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11912.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9829.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11094.32, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12651.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9731.86, "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": 17634.13, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 13683, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14208.52, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11444.67, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10315.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 11327.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15570.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11327.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11678.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11561.45, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11327.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10187.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9731.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15826.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11094.32, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6393.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3128.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8205, "minimum": 5474.34, "maximum": 14868.2029, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13336.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8369.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9551.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 9994.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8287.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9354.17, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10667.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8205.41, "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": 14868.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 11536.81, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11979.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9649.56, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8697.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9551.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13128.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9551.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9846.49, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9748.03, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9551.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5474.34 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8205.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13749.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9354.17, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACOUS ELECTR CARD MULTI AV+VV", "code_information": [ { "code": "93799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408.96, "discounted_cash": 164, "minimum": 122.688, "maximum": 408.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 212.6, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 174.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 214.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 4", "code_information": [ { "code": "5644", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14390.43, "maximum": 15397.76, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15397.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACOUS ELECTR CARD MULTI AV/VV", "code_information": [ { "code": "94799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408.96, "discounted_cash": 164, "minimum": 64.5, "maximum": 1163.55, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 212.6, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 174.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 214.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6851.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACTIN SMOOTH MUSCLE AB QN*LC", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.76, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "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": 8.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACCA ALCA AMCA", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "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": 11.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.04, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.43, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACOUS ELECTR CARDGRAPHY SINGLE", "code_information": [ { "code": "93799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408.96, "discounted_cash": 164, "minimum": 122.688, "maximum": 408.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 212.6, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 174.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 214.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACETAMNOPHN QNT - 80143 - 4152003", "code_information": [ { "code": "80143", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 267.94, "discounted_cash": 18, "minimum": 1.875, "maximum": 267.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 27.96, "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": 18.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 15.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.06, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.31, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACTYCHLN RCPTR BLCKNG AB", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.88, "discounted_cash": 36, "minimum": 7.464, "maximum": 26.72, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "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": 24.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 24.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 24.88, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACTVTY THRPY 45", "code_information": [ { "code": "G0176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 141.6, "minimum": 35, "maximum": 178.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise 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": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "description": "ACULAR", "drug_information": { "unit": 3, "type": "ML" }, "code_information": [ { "code": "42571013725", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ACETAMINOPHEN", "code_information": [ { "code": "80299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.2, "discounted_cash": 18, "minimum": 5.313, "maximum": 149.85, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.19 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 27.96, "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": 18.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "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": 13.86, "10th_percentile": 13.86, "90th_percentile": 13.86, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 15.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.06, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.31, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.56, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.33, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACTVTY THRPY 60", "code_information": [ { "code": "G0176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 178.8, "minimum": 35, "maximum": 178.8, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 36.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 84.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise 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": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 35 } ] } ] }, { "description": "ACTVTY THRPY 30", "code_information": [ { "code": "90899", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104.6, "discounted_cash": 47, "minimum": 31.38, "maximum": 104.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 71.93, "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": 48.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 60.01, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 67.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 67.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 70.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.9, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 63.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 60.01, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10507.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACR BNDNG AB* LC", "code_information": [ { "code": "84238", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.72, "discounted_cash": 36, "minimum": 7.464, "maximum": 26.72, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "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": 26.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 8710.35, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8710.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20067.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16391, "minimum": 9190.73, "maximum": 29702.0503, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22494.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16719.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19080.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16391.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20277.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16555.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18686.72, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21309.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16391.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16391.86, "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": 29702.05, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 23046.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23932.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19276.83, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17375.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16391.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16391.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19080.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26226.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19080.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19670.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19473.53, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19080.13, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9190.73 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16391.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23190.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18686.72, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACTIVATED CLOTTING TIME i-STAT", "code_information": [ { "code": "85347", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.4, "discounted_cash": 4, "minimum": 4.19, "maximum": 21.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.51 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.42, "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": 4.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.58, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.19 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.36, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14124.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION", "code_information": [ { "code": "880", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9329, "minimum": 2800, "maximum": 16905.7969, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13676.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9516.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10860.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11407.18 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9423.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10636.1, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12128.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9329.91, "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": 16905.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 13117.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13621.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10971.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9889.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10860.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14927.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10860.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11195.89, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11083.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10860.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7839.76 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9329.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14099.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10636.1, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25842, "minimum": 25842.79, "maximum": 46827.1355, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38970.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 26359.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30081.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25842.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 32149.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 26101.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29460.78, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 33595.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25842.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25842.79, "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": 46827.14, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 36334.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37730.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30391.12, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27393.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25842.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25842.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 30081.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 41348.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30081.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31011.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30701.23, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30081.01, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35684.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25842.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40175.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29460.78, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 3", "code_information": [ { "code": "4693", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8886.82, "maximum": 9508.9, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9508.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9041, "minimum": 9041.45, "maximum": 16383.1074, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13967.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9222.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10524.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11044.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9131.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10307.25, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11753.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9041.45, "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": 16383.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 12712.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13200.52, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10632.75, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9583.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10524.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14466.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10524.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10849.74, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10741.24, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10524.25, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12969.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9041.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14399.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10307.25, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3565.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 2", "code_information": [ { "code": "7562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4969.75, "maximum": 5317.63, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5317.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18265.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5214.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7521.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11743.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15211.37, "maximum": 16276.17, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16276.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11684.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11782, "minimum": 10800, "maximum": 21349.437, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11782.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13714.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18851.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13714.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14138.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13997.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13714.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16833.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18689.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13431.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18129.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12017.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13714.54, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11782.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14487.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11900.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13431.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15316.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11782.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11782.25, "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": 21349.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 16565.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17202.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11782.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13855.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12489.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11782.25, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 1", "code_information": [ { "code": "1451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3855.58, "maximum": 4125.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4125.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25746.65, "maximum": 27548.92, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27548.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8594.23, "maximum": 9195.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9195.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7680, "minimum": 3694.91, "maximum": 13917.0841, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9677.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7834.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8940.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 9335.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7757.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8755.78, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9984.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7680.51, "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": 13917.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 10798.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11213.54, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9032.28, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8141.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8940.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12288.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8940.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9216.61, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9124.45, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8940.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3694.91 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7680.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9976.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8755.78, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7257.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19975, "minimum": 19800, "maximum": 36195.298, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30473.04 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20374.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23251.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19975.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24779.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20175.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22771.88, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25967.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19975.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19975.33, "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": 36195.3, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 28085.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29163.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23490.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21173.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19975.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19975.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23251.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31960.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23251.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23970.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23730.69, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23251.28, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24083.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19975.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31415.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22771.88, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7104.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4294.49, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52169, "minimum": 42300, "maximum": 108682, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78858.28 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53213.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60725.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 52169.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 65220.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 52691.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59473.54, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 67820.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 52169.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 52169.77, "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": 94531.62, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 73350.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 76167.86, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61351.65, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55299.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52169.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52169.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 60725.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83471.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60725.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62603.72, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61977.69, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60725.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 108682 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52169.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81297.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59473.54, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10157.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7087, "minimum": 7087.52, "maximum": 12842.5862, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10345.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7229.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8249.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8590.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7158.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8079.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9213.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7087.52, "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": 12842.59, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9965.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10347.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8334.92, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7512.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8249.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11340.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8249.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8505.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8419.97, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8249.87, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10994 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7087.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10665 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8079.77, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11250, "minimum": 5761.97, "maximum": 20386.3409, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16595.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11475.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11250.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13820 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11363.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12825.84, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14625.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11250.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11250.74, "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": 20386.34, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15818.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16426.08, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13230.87, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11925.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11250.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11250.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18001.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13500.89, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13365.88, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13095.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5761.97 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11250.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17108.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12825.84, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16196.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6795, "minimum": 6795.29, "maximum": 12313.0655, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10571.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6931.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7909.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8223.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6863.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7746.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8833.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6795.29, "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": 12313.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9554.18, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9921.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7991.26, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7203.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7909.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10872.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7909.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8154.35, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8072.8, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7909.72, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9816.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6795.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10898.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7746.63, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48234.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE VIRAL HEP (HAV,HBV,HCV)", "code_information": [ { "code": "80074", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.74, "discounted_cash": 47, "minimum": 4.722, "maximum": 15.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "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": 15.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8941, "minimum": 8941.2, "maximum": 16201.4544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13151.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9120.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10407.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10918.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9030.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10192.97, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11623.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8941.2, "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": 16201.45, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 12571.33, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13054.15, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10514.85, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9477.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10407.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14305.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10407.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10729.44, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10622.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10407.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12256.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8941.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13558.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10192.97, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRNSFR,10.1-30SQ CM", "code_information": [ { "code": "14041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4792, "discounted_cash": 2640, "minimum": 605.06, "maximum": 4792, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 635.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "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": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 647.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3409.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": 605.06 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3443.97, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15419, "minimum": 15419.6, "maximum": 27940.3696, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17948.45, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24671.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17948.45, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18503.56, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18318.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17948.45, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18181 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24142.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17578.38, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23417.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15727.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17948.45, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19056.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15573.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17578.38, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20045.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27940.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 21680, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22512.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18133.48, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16344.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15419.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15419.6, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRNSF,10.1-30SQ CM", "code_information": [ { "code": "14061", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4792, "discounted_cash": 2640, "minimum": 1062.72, "maximum": 4792, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1115.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "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": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1137.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3409.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "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": 1062.72 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3443.97, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1062.72 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3142.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18982, "minimum": 14400, "maximum": 34395.9095, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27897.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19361.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22095.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18982.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23531.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19172.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21639.81, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24676.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18982.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18982.29, "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": 34395.91, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 26689.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27714.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22323.17, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20121.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18982.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18982.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22095.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30371.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22095.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22778.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22550.96, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22095.39, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33747.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18982.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28760.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21639.81, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 1", "code_information": [ { "code": "7551", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2180.63, "maximum": 2333.27, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2333.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADMIN INFLUENZA VIRUS VAC", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154.35, "discounted_cash": 59, "minimum": 25, "maximum": 154.35, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.99, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 77.36, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.99, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5912, "minimum": 5850, "maximum": 10714.1748, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8009.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6031.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6882.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7114.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5972.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6740.71, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7686.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 5912.9, "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": 10714.17, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 8313.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8632.83, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6953.57, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6267.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 6882.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9460.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6882.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7095.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7024.53, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6882.62, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7437.56 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5912.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8257.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6740.71, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9243.46, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADMIN PNEUMOCOCCAL VACCINE", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154.35, "discounted_cash": 59, "minimum": 33.327, "maximum": 154.35, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.99, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 77.36, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 74.99, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AEROSOL TX", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1322.25, "discounted_cash": 280, "minimum": 16.78, "maximum": 1322.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ADM EA ADD VACC", "code_information": [ { "code": "90472", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 120, "minimum": 4.683, "maximum": 120, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.68 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13482, "minimum": 6750, "maximum": 24430.6886, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20444.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13752.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15693.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13482.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16623.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13617.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15370.3, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17527.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13482.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13482.72, "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": 24430.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 18956.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19684.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15855.68, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14291.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13482.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13482.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15693.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21572.35, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15693.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16179.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16017.47, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15693.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19676.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13482.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21077 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15370.3, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFP TUMOR MRKR* LC", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.54, "discounted_cash": 16, "minimum": 2.187, "maximum": 33.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.99, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.58 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.65, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.87, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.54 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.99, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRNSF,10SQ CM/LESS", "code_information": [ { "code": "14060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4792, "discounted_cash": 2640, "minimum": 605.06, "maximum": 4792, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 635.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "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": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 647.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3409.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": 605.06 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3443.97, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 605.06 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AEROBIC IDENTIFICATION LC", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.22, "discounted_cash": 8, "minimum": 3.666, "maximum": 49.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "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": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "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": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% 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": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34468, "minimum": 18450, "maximum": 62456.161, "payers_information": [ { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41361.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40948.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40120.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47255.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52467.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39293.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50893.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 35157.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40120.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 34468.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42984.22 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34812.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39293.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 44808.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 34468.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 34468.08, "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": 62456.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 48462.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50323.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40534.46, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36536.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 34468.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34468.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34468.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 40120.85, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55148.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40120.85, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ADJ TISSUE TRNSFR,10 SQCM/LESS", "code_information": [ { "code": "14040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4792, "discounted_cash": 2640, "minimum": 483.82, "maximum": 4792, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.36, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 508.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3961.08, "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": 2667.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3855.45, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3409.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3443.97, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3304.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AFP TUMOR MARKER SERUM LC", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.77, "discounted_cash": 16, "minimum": 2.187, "maximum": 33.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "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": 16.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 2", "code_information": [ { "code": "4012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13076.33, "maximum": 13991.67, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13991.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Airway Resistance", "code_information": [ { "code": "94726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 638.9, "discounted_cash": 477, "minimum": 37.99, "maximum": 638.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 610.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 487.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 610.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50.49 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 638.9, "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": 482.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 597.7, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 638.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 638.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 638.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 616.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 506.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 610.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 610.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 629.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 622.86, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 610.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 37.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 477.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 629.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 597.7, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5823.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10898, "minimum": 10898.9, "maximum": 19748.843, "payers_information": [ { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12686.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 10898.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13378.07 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11007.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12424.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14168.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 10898.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 10898.92, "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": 19748.84, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15323.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15912.42, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12817.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11552.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 10898.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10898.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12686.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17438.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12686.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13078.7, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12947.92, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12686.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18614.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16748.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12424.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16245.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11116.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10898.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 4", "code_information": [ { "code": "7724", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18947.17, "maximum": 20273.47, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20273.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20977, "minimum": 12150, "maximum": 38011.828, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32514.59 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21397.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24418.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 26038.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21187.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23914.73, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 27271.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38011.83, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 29494.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30627.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24669.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22236.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24418.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33564.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24418.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25173.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24921.66, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24418.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32446.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20977.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33520.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23914.73, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7851, "minimum": 7851.69, "maximum": 14227.2623, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11664.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8008.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9139.37, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 9550.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7930.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8950.93, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10207.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7851.69, "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": 14227.26, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 11039.48, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11463.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9233.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9139.37, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12562.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9139.37, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9422.03, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9327.81, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9139.37, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11923.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7851.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12025.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8950.93, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC CULTURE LC", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.4, "discounted_cash": 8, "minimum": 1.596, "maximum": 467.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "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": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.13, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.24, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% 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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3518.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25772.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43397, "minimum": 19350, "maximum": 78636.9948, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69720.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44265.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50515.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 54201.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 43831.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49473.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 56417.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 43397.9, "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": 78636.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 61017.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 63360.93, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51035.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46001.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 50515.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 69436.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50515.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52077.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51556.71, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50515.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64736.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43397.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71876.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49473.61, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AEROBIC ID", "code_information": [ { "code": "87077", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.5, "discounted_cash": 8, "minimum": 3.666, "maximum": 49.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "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": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "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": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% 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": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5078.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48465.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AIRWAY INHALATION TREATMENT", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 957.5, "discounted_cash": 280, "minimum": 16.78, "maximum": 1322.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AFB CULTURE & SMEAR*FOCUS", "code_information": [ { "code": "87015", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45, "discounted_cash": 6, "minimum": 6.67, "maximum": 107, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.02, "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": 6.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.36, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL ETHYL", "code_information": [ { "code": "80307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 316.2, "discounted_cash": 62, "minimum": 7.2, "maximum": 798.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 79.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 79.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 45.68 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 93.21, "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": 62.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 77.77, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "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": 46.55, "10th_percentile": 46.55, "90th_percentile": 46.55, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 87.37 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 90.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 80.22, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.87, "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": 43.5, "10th_percentile": 43.5, "90th_percentile": 43.5, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 79.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 79.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 81.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 81.04, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 79.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 62.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 81.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 77.77, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AER DEMO/EVAL", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240.9, "discounted_cash": 280, "minimum": 12.34, "maximum": 559.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "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": 240.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 240.9, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALA AMINOLEVULINIC ACID*LC", "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": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.59, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.59, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.13 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.24, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.79 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.45, "additional_payer_notes": "100.00% 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 } ] } ] }, { "description": "AFB ID BY SEQUENCING LC", "code_information": [ { "code": "87153", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 250, "discounted_cash": 115, "minimum": 75, "maximum": 250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 117.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 107.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 173.04, "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": 116.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 144.37, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 162.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 168.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 148.93, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 122.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 151.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 147.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 82.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 151.97, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 144.37, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 2", "code_information": [ { "code": "2802", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6415.73, "maximum": 6864.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6864.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AEROBIC BACTERIAL CULT LC", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.14, "discounted_cash": 8, "minimum": 1.596, "maximum": 467.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "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": 8.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALBUMIN SERUM - 82040 - 4152040", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.81, "discounted_cash": 4, "minimum": 3.429, "maximum": 94.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "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": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALKALINE PHOS ISOENZYME LC", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 14, "minimum": 1, "maximum": 30, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "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": 2.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AEROBIC SENSITIVITY*SOH", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 96, "discounted_cash": 8, "minimum": 1.5, "maximum": 96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.16 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.17, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.28, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.83, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 1", "code_information": [ { "code": "7721", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3856.64, "maximum": 4126.6, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4126.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFP WITH AFP-L3% LC", "code_information": [ { "code": "82107", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75, "discounted_cash": 64, "minimum": 22.5, "maximum": 75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 65.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 60.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 65.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 68.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.81 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 64.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 75, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 4107311", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.62, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AFB CULTURE AND SMEAR LC", "code_information": [ { "code": "87116", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.41, "discounted_cash": 10, "minimum": 8.922, "maximum": 393.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.58 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "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": 10.91, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.94, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.09, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8887.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFRIN NASAL 0.05% SPRAY", "drug_information": { "unit": 15, "type": "ML" }, "code_information": [ { "code": "54569215400", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16223.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFB ID DNA PROBE LC", "code_information": [ { "code": "87149", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.75, "discounted_cash": 20, "minimum": 12.99, "maximum": 109.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.05 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 30.08, "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": 20.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.09, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 28.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 28.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.88, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.99 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.09, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6083, "minimum": 2129.4, "maximum": 11022.6316, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8904.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6204.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7080.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7328.77 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6143.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6934.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7908.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6083.13, "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": 11022.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 8552.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8881.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7153.76, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6448.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7080.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9733.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7080.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7299.76, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7226.76, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7080.76, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4604.32 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6083.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9179.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6934.77, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11500, "minimum": 11500.4, "maximum": 29440, "payers_information": [ { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13110.48, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14950.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11500.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11500.42, "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": 20838.76, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 16169.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16790.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13524.49, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12190.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11500.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11500.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13386.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18400.67, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13386.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13800.5, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13662.5, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13386.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29440 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15870.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13110.48, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15394.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11730.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13386.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11500.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11500.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14133.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11615.4, "additional_payer_notes": "101.00% 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59181.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6185, "minimum": 6185.27, "maximum": 23503.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8361.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6308.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7199.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7457.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6247.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7051.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8040.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6185.27, "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": 11207.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 8696.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9030.49, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7273.88, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6556.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7199.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9896.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7199.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7422.32, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7348.1, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7199.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23503.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6185.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8620.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7051.21, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10436.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17886, "minimum": 17886.15, "maximum": 32409.7038, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26483.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18243.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20819.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17886.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22155.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18065.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20390.21, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23252, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17886.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17886.15, "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": 32409.7, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 25147.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26113.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21034.11, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18959.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17886.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17886.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20819.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28617.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20819.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21463.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21248.75, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20819.48, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24591 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17886.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27303 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20390.21, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 346.3, "discounted_cash": 15, "minimum": 1.5, "maximum": 346.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.2 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.67, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALBUMIN SERUM - 82040 - 4102040", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 94.7, "discounted_cash": 4, "minimum": 3.429, "maximum": 94.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "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": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALDOSTERONE* LC", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 81.5, "discounted_cash": 40, "minimum": 5.52, "maximum": 81.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 57.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 57.29 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.61, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20654.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMIKACIN RANDOM SERUM", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10, "discounted_cash": 15, "minimum": 1.5, "maximum": 346.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "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 Medi-Cal IPA", "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": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 2", "code_information": [ { "code": "7722", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4532.99, "maximum": 4850.3, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4850.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13636, "minimum": 7706.4, "maximum": 34200, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20657.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13909.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15873.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13636.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16817.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13773.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15546.04, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17727.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13636.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13636.88, "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": 24710.03, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 19173.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19909.84, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16036.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14455.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13636.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13636.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15873.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21819.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15873.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16364.26, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16200.61, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15873.33, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8783.77 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13636.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21296.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15546.04, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMIKACIN TROUGH LC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5, "discounted_cash": 15, "minimum": 1.5, "maximum": 346.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% 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": 5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7341.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN SPEC IGE RECOMB EA", "code_information": [ { "code": "86008", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.65, "discounted_cash": 17, "minimum": 2.595, "maximum": 8.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "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": 8.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALDOSTERONE, 24 HRS URINE", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21, "discounted_cash": 40, "minimum": 5.52, "maximum": 81.5, "payers_information": [ { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "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 Medi-Cal IPA", "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": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21, "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": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "127.78% 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": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AMOEBIASIS*LC", "code_information": [ { "code": "86753", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.45, "discounted_cash": 12, "minimum": 8.1, "maximum": 37.45, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "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": 12.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.09 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.63 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "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": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.16, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.83, "additional_payer_notes": "127.78% 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": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "125.15% of Medicare 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": 16753, "minimum": 4867.2, "maximum": 30356.6897, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25406.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 17088.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19500.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16753.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 20731.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16920.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19098.58, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 21779.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16753.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16753.14, "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": 30356.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 23554.91, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24459.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19701.69, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17758.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16753.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16753.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 19500.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26805.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19500.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20103.77, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19902.73, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19500.65, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13990.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16753.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26192.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19098.58, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA12 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.98, "discounted_cash": 16, "minimum": 2.595, "maximum": 106.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "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": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 17.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% 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": 16.75 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.65, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare 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": 21771, "minimum": 21771.3, "maximum": 39449.6318, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30778.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22206.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25341.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21771.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27035.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21989.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24819.3, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28302.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21771.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21771.32, "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": 39449.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 30610.48, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31786.13, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25603.07, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23077.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21771.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21771.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25341.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34834.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25341.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26125.58, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25864.33, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25341.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24953.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21771.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31730.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24819.3, "additional_payer_notes": "114.00% of Medicare 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": 8597, "minimum": 3346.2, "maximum": 15579.3948, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12586.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8769.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10007.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10487.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8683.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9801.61, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11177.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8597.9, "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": 15579.39, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 12088.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12552.93, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10111.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9113.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10007.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13756.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10007.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10317.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10214.31, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10007.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12975.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9801.61, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71097.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 4107308", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.88, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare 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": 11410, "minimum": 10268.4, "maximum": 20675.9528, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16593.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11638.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13281.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11410.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14020.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11524.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13008.05, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14833.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11410.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11410.57, "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": 20675.95, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 16043.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16659.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13418.83, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12095.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11410.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11410.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13281.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18256.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13281.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13692.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13555.76, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13281.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10268.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11410.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17107.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13008.05, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 1", "code_information": [ { "code": "2801", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4881.76, "maximum": 5223.48, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5223.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 160324.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA13 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.87, "discounted_cash": 16, "minimum": 2.595, "maximum": 106.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "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": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 17.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% 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": 16.75 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19795.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20585.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5234.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Allergens (7) Seafood", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.82, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3027.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANA PANEL, LC", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 116.75, "discounted_cash": 12, "minimum": 1.248, "maximum": 116.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN PROFILE, FOOD", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.12, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4368.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE LC - 87075 - 7006375", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.4, "discounted_cash": 9, "minimum": 3.057, "maximum": 278.81, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "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": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN SPECIFIC IGE QN/SQ LC - 86003 - 4107313", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.98, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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" } ] } ] }, { "description": "AMIKACIN PEAK SERUM LC", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5, "discounted_cash": 15, "minimum": 1.5, "maximum": 346.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% 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": 5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16152, "minimum": 16152.59, "maximum": 29268.4931, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24794.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 16475.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18801.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 16152.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19977.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 16314.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18413.95, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20998.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 16152.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 16152.59, "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": 29268.49, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 22710.54, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23582.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18995.45, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17121.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 16152.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16152.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18801.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25844.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18801.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19383.11, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19189.28, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18801.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18376.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16152.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25561.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18413.95, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE LC - 87075 - 7006394", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.66, "discounted_cash": 9, "minimum": 3.057, "maximum": 278.81, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.21, "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": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.35, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGEN W/TOTAL IGE AREA17 LC", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.62, "discounted_cash": 16, "minimum": 2.595, "maximum": 106.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.24 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.69, "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": 16.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 23.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 17.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% 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": 16.75 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.75 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.6, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AMIODARONE", "code_information": [ { "code": "80299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.16, "discounted_cash": 18, "minimum": 5.313, "maximum": 149.85, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.19 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 18.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6550, "minimum": 5271.46, "maximum": 11869.2161, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9474.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6681.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7624.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7915.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7467.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8515.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6550.34, "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": 11869.22, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9209.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9563.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7703.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6943.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7624.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10480.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7624.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7860.41, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7781.8, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7624.6, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5271.46 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6550.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9767.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7467.39, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7134.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGENS (7) SEAFOODS LC", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.52, "discounted_cash": 5, "minimum": 1.2, "maximum": 42.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AMMONIA", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 222.6, "discounted_cash": 14, "minimum": 14.57, "maximum": 222.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 3", "code_information": [ { "code": "0073", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89273.14, "maximum": 95522.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 95522.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANCA", "code_information": [ { "code": "86036", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20, "discounted_cash": 12, "minimum": 6, "maximum": 82.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.56, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8585.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10065.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANCA PANEL, LC2", "code_information": [ { "code": "86256", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.58, "discounted_cash": 12, "minimum": 1.788, "maximum": 83, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.56, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 113908, "minimum": 113908.66, "maximum": 206402.4919, "payers_information": [ { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 132589.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 182253.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 132589.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 136690.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 135323.49, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 132589.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 113908.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 140174 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 192705.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 129855.87, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 186924.14 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 116187.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 132589.68, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 113908.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 142772.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 115048.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 129855.87, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 148081.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 113908.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 113908.66, "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": 206402.49, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 160155.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 166306.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 133956.58, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 120743.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 113908.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 113908.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 113909, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 4", "code_information": [ { "code": "3054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31219.94, "maximum": 33405.34, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33405.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9738.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6939.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": 33231, "minimum": 29302.7, "maximum": 60214.6264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55142.17 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33895.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38680.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 33231.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41430.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33563.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37883.37, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43200.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33231.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 33231.03, "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": 60214.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 46722.83, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 48517.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39079.69, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35224.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33231.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33231.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38680.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53169.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38680.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39877.24, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39478.46, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38680.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33231.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29302.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33231, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56847.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37883.37, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Amiodarone (Cordarone)* LC", "code_information": [ { "code": "82542", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.16, "discounted_cash": 24, "minimum": 1.956, "maximum": 300, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 20.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.16, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 4", "code_information": [ { "code": "0524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15262.26, "maximum": 16330.62, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16330.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8482, "minimum": 7650, "maximum": 15370.3081, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12567.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8652.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9873.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10342.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8567.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9670.06, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11027.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8482.51, "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": 15370.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 11926.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12384.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9975.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8991.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9873.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13572.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9873.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10179.01, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10077.22, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9873.64, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8807.64 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8482.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12956.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9670.06, "additional_payer_notes": "114.00% of Medicare 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": 13341, "minimum": 13341.8, "maximum": 24175.3416, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21541.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13608.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15529.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16446.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13475.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15209.65, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17344.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13341.8, "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": 24175.34, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 18758.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19479.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15689.96, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14142.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15529.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21346.88, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15529.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16010.16, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15850.06, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15529.86, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20002.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13341.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22208.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15209.65, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "Androstenedione,ACTH Stimulati", "code_information": [ { "code": "82157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40, "discounted_cash": 29, "minimum": 12, "maximum": 40, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 40, "additional_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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 40, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.8, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 37.41, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 29.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 38.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 36.64, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC", "code_information": [ { "code": "240", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27207, "minimum": 24871.4, "maximum": 49300.0262, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41548.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 27751.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31669.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 27207.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 33863.94 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 27479.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31016.57, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 35369.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 27207.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 27207.52, "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": 49300.03, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 38253.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 39722.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31996.04, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28839.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 27207.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27207.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 31669.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 43532.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31669.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32649.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32322.53, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31669.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24871.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27207.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42833.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31016.57, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AMYLASE - 82150 - 4102150", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 324.8, "discounted_cash": 6, "minimum": 6.48, "maximum": 324.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.37, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.11, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 6695.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6695.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC", "code_information": [ { "code": "239", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46795, "minimum": 46795.99, "maximum": 84794.3339, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71861.77 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 47731.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54470.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 46795.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 58469.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 47263.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53347.43, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 60834.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 46795.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 46795.99, "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": 84794.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 65795.16, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 68322.15, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55032.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49603.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 46795.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46795.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 54470.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74873.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54470.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56155.19, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55593.64, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54470.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46795.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47229.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46796, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74084.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53347.43, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8792.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Angiotensin-convrtng Enzyme*LC", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.2, "discounted_cash": 14, "minimum": 1.719, "maximum": 29.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.52 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.53 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.04, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.27, "additional_payer_notes": "125.15% of Medicare 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": 40849, "minimum": 40849.09, "maximum": 74018.5511, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 63983.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 41666.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47548.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 40849.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 50999.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 41257.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46567.96, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 53103.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40849.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 40849.09, "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": 74018.55, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 57433.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59639.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48038.53, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43300.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40849.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40849.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 47548.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65358.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47548.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49018.91, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48528.72, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47548.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68842.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40849.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65962.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46567.96, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 3", "code_information": [ { "code": "2263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12875.97, "maximum": 13777.29, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13777.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Angiotnsn Convrtng Enzym(ace)", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.73, "discounted_cash": 14, "minimum": 1.719, "maximum": 29.2, "payers_information": [ { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "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": 5.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 2", "code_information": [ { "code": "3052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12581.27, "maximum": 13461.96, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13461.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12581.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANCA SCREEN EA AB", "code_information": [ { "code": "86036", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 82.5, "discounted_cash": 12, "minimum": 6, "maximum": 82.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.56, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANKLE 3 VWS MIN", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 477, "discounted_cash": 111, "minimum": 26.32, "maximum": 477, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 37.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "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": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 118.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 145.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare 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": 17937, "minimum": 17937.2, "maximum": 32502.2608, "payers_information": [ { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20448.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27558.28 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18295.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20878.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17937.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22219.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18116.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20448.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23318.4, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17937.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17937.23, "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": 32502.26, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 25219.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26188.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21094.18, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19013.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17937.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17937.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20878.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28699.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20878.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21524.68, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21309.43, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20878.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18141.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17937.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28410.6 } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5172.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7852.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "618", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13662, "minimum": 13662.4, "maximum": 24756.2869, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17763.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13935.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15903.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13662.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16849.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13799.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15575.15, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17761.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13662.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13662.41, "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": 24756.29, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 19209.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19947.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16066.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14482.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13662.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13662.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15903.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21859.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15903.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16394.89, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16230.94, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15903.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16494.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13662.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18313.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15575.15, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANKLE 2 VWS", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 290.5, "discounted_cash": 111, "minimum": 19.92, "maximum": 290.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 113.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 167.06, "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": 112.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 155.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 156.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 162.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 143.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 118.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 145.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 142.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 111.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 139.38, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 1", "code_information": [ { "code": "1981", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3984.92, "maximum": 4263.86, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4263.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9165.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMYLASE - 82150 - 4152150", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 157.8, "discounted_cash": 6, "minimum": 6.48, "maximum": 324.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.37, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.11, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17721.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11657.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAEROBIC CULTURE*SOH", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "discounted_cash": 9, "minimum": 3.057, "maximum": 278.81, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 14.21, "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": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.83 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.23, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.35, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27433.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOSCOPY HRA DX W/COLLECTION", "code_information": [ { "code": "46601", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 315.12, "discounted_cash": 571, "minimum": 94.536, "maximum": 315.12, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.31 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "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": 315.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 315.12, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI SMITH AB* LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.54, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANAEROBIC ID", "code_information": [ { "code": "87076", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.5, "discounted_cash": 8, "minimum": 8.08, "maximum": 126.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "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": 8.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.11, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3476.19, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14144.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-CARDIOLIPIN AB lgM*LC1", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.9, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 38.18, "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": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 35.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.86, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23223.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI SAC IGG QL", "code_information": [ { "code": "83520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35, "discounted_cash": 17, "minimum": 2.355, "maximum": 365.32, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "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": 17.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.61, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 24.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.3, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.52, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.61, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2268.08, "maximum": 2426.85, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2426.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTI-SCL 70", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.46, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 11.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12626, "minimum": 12626.8, "maximum": 22879.7797, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17960.81 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12879.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14697.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12626.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15548.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12753.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14394.56, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16414.85, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12626.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12626.81, "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": 22879.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 17753.29, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18435.14, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14849.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13384.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12626.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12626.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14697.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20202.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14697.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15152.17, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15000.65, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14697.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16037.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12626.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18516.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14394.56, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI-CENTROMERE AB LC", "code_information": [ { "code": "86256", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83, "discounted_cash": 12, "minimum": 1.788, "maximum": 83, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.94 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.56, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.92 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI MULLERIAN HORMONE AMH LC", "code_information": [ { "code": "82397", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42, "discounted_cash": 14, "minimum": 4.398, "maximum": 400, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.18, "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": 14.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.67, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.41, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.04, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.67, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI-SM AB LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 26.9, "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": 18.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.44, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.15, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.38, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.44, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21959, "minimum": 21959.5, "maximum": 39790.6502, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33767.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 22398.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 21959.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 27271.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 22179.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25033.85, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 28547.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 21959.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 21959.52, "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": 39790.65, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 30875.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32060.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25824.4, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23277.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 21959.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21959.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35135.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26351.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26087.91, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25560.88, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31353 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21959.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34811.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25033.85, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTICARDIOLIPIN AB LC", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.82, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "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": 10.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTIPARIETAL CELL AB,QN*LC", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.42, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "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": 10.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.42, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI-THROMBIN III PANEL, LC", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.25, "discounted_cash": 11, "minimum": 7.098, "maximum": 38.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.83, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.66 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.83, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTICHROMATIN ANTIBODIES LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.93, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "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": 17.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTITRYPSIN AB", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.88, "discounted_cash": 13, "minimum": 1.578, "maximum": 61.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.9 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.35, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.53, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI-TPO AB (RDL) LC", "code_information": [ { "code": "86376", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 14, "minimum": 1.719, "maximum": 66, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.98, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.83, "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": 14.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.24 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.84 } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6887, "minimum": 6887.02, "maximum": 12479.2802, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9962.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7024.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8016.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8338.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6955.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7851.2, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8953.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6887.02, "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": 12479.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9683.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10055.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8099.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7300.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8016.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11019.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8016.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8264.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8181.78, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8016.49, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7879.14 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6887.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10270.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7851.2, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTIHISTONE ANTIBODY *LC", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.72, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "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": 16.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.72, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AORT/INF/IV/BPG", "code_information": [ { "code": "93978", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1016, "discounted_cash": 305, "minimum": 171.88, "maximum": 1359, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 247.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 183.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 394.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 398.27, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTIBODY TITER $$AB TITER*LS", "code_information": [ { "code": "86886", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "discounted_cash": 218, "minimum": 4.84, "maximum": 856.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "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": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 78, "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": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "127.78% 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": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANOSCOPY HRA W/ BIOPSIES", "code_information": [ { "code": "46607", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2809.17, "discounted_cash": 1531, "minimum": 146.3595, "maximum": 2809.17, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1562.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 146.36 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1916.7, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1977.22, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1997.4, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1916.7, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APO-PEN VK", "drug_information": { "unit": 500, "type": "ME" }, "code_information": [ { "code": "00781165501", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "AORTA/ ILIAC DUPLEX SCAN", "code_information": [ { "code": "93978", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1016, "discounted_cash": 305, "minimum": 171.88, "maximum": 1359, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 247.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 183.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 394.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 398.27, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.88 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTICRDLPIN AB,lgA/lgG/lgM*LC1", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.46, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "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": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 32.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4521.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12031.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APIXABAN ANTI-Xa", "code_information": [ { "code": "85130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195, "discounted_cash": 11, "minimum": 11.89, "maximum": 195, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 17.84, "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": 12.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.88, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.98 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.35, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.66, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.88, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "Antiextractable Nuclar Antigns", "code_information": [ { "code": "86235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.54, "discounted_cash": 17, "minimum": 2.256, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.54, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 3", "code_information": [ { "code": "0593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10738.81, "maximum": 11490.53, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23121.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25805.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Antigen Type,Per Antigen/Unit", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 458, "minimum": 2.62, "maximum": 105.65, "payers_information": [ { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 52, "additional_payer_notes": "100.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4665.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ART DPLR LW EXT", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1416, "discounted_cash": 170, "minimum": 50.82, "maximum": 1416, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 219.83, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 222.08, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9643.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTINUCL AB(ANA* LC", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.18, "discounted_cash": 12, "minimum": 1.248, "maximum": 116.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14182.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ART/VEN FLW LTD", "code_information": [ { "code": "93976", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 910.9, "discounted_cash": 133, "minimum": 133.8, "maximum": 1061, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 233.03 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "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": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 187.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 172.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 141.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 174.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14329.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40189, "minimum": 6750, "maximum": 72824.0988, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59360.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 40993.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46781.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 50171.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 40591.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45816.49, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 52246.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 40189.9, "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": 72824.1, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 56507, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 58677.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47263.32, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42601.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 46781.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 64303.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46781.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48227.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47745.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 46781.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8185.85 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40189.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61196.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45816.49, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ANTI CARDIOLIP AB", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.82, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "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": 10.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.82, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JT*INTERMED", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1237.4, "discounted_cash": 392, "minimum": 54.46, "maximum": 6000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 57.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 507.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "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": 54.46 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.36, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.46 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APRESOLINE - 00904644161", "drug_information": { "unit": 25, "type": "ME" }, "code_information": [ { "code": "00904644161", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "Apolipoprotein B", "code_information": [ { "code": "82172", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.6, "discounted_cash": 21, "minimum": 10.08, "maximum": 33.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.39, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.65 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.23, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.39, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ANTI-CARDIOLIPIN AB lgG*LC1", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.9, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 38.18, "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": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 35.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.86, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASCA IgG", "code_information": [ { "code": "86671", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20, "discounted_cash": 12, "minimum": 6, "maximum": 20, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 17.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.22 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.81, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.98, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ART/VEN FLW COM", "code_information": [ { "code": "93975", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1056.6, "discounted_cash": 305, "minimum": 175.13, "maximum": 2000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 282.91 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 187.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 394.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 398.27, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.13 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9338.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTIMYELOPEROXIDASE (MPO)", "code_information": [ { "code": "83516", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.14, "discounted_cash": 11, "minimum": 1.245, "maximum": 220, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "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": 11.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.87 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASPERGILLUS AG BAL/SERUM LC", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.5, "discounted_cash": 11, "minimum": 6.93, "maximum": 59.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.09 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.99, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.84 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.47, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.62, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.99, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ARTERY DUPLEX UPPER EXTRM", "code_information": [ { "code": "93930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1445.4, "discounted_cash": 305, "minimum": 105.4, "maximum": 1445.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 140.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 394.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 398.27, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.4 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 382.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2333", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15997.97, "maximum": 17117.83, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17117.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASSAY OF G6PD ENZYME", "code_information": [ { "code": "82955", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.67, "discounted_cash": 9, "minimum": 1.101, "maximum": 3.67, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "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": 3.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JNT,MAJOR", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1237.4, "discounted_cash": 392, "minimum": 65.68, "maximum": 6000, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 68.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 507.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.36, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 65296, "minimum": 18007.9, "maximum": 118317.8922, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 95127.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 66602.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76005.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 65296.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 81709.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 65949.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74438.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 84885.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 65296.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 65296.85, "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": 118317.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 91807.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 95333.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76789.1, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 69214.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 65296.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 65296.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 76005.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 104474.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76005.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78356.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77572.66, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76005.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18007.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65296.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 98069.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74438.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY PHENYTOIN TOTAL", "code_information": [ { "code": "80185", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.25, "discounted_cash": 13, "minimum": 1.875, "maximum": 425.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "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": 6.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "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 Medi-Cal IPA", "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": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18000, "maximum": 25838.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25062.96 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23271 }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25838.1 } ] } ] }, { "description": "APS COMP(ESOTERIX) LC", "code_information": [ { "code": "85597", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.05, "discounted_cash": 17, "minimum": 17.98, "maximum": 132.05, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 25.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 26.97, "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": 18.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.21, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.45, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.98, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.69, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7560.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASSAY URINE CREATININE LC", "code_information": [ { "code": "82570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.18, "discounted_cash": 5, "minimum": 1.086, "maximum": 232.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "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": 5.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "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 Medi-Cal IPA", "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": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASPERGILLUS AB, CF QN *LC", "code_information": [ { "code": "86606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.82, "discounted_cash": 15, "minimum": 2.178, "maximum": 21.82, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 21.82, "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": 15.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.83, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.82 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.83, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL DOPPLER UPPER EXT.", "code_information": [ { "code": "93922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1416, "discounted_cash": 170, "minimum": 50.82, "maximum": 1416, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 219.83, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 222.08, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.82 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14563, "minimum": 13500, "maximum": 31212.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21588.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14854.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16952.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14563.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17981.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14709.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16602.64, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18932.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14563.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14563.72, "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": 26389.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 20476.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21263.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17126.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15437.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14563.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14563.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16952.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23301.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16952.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17476.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17301.7, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16952.17, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31212.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14563.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22256.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16602.64, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AT ANTIGEN IMMUNOLOGIC LC", "code_information": [ { "code": "85301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.15, "discounted_cash": 10, "minimum": 2.445, "maximum": 8.15, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "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": 8.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASPIRIN - 00363021807", "drug_information": { "unit": 81, "type": "ME" }, "code_information": [ { "code": "00363021807", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ARTHROCENT ASP/INJ JT,SMALL", "code_information": [ { "code": "20600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 739, "discounted_cash": 392, "minimum": 46.46, "maximum": 739, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.78 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 507.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "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": 46.46 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.36, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22898, "minimum": 22898.66, "maximum": 41492.3719, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34711.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36444.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26104.47, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35350.87 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23356.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26654.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 22898.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 28451.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23127.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26104.47, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 29768.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 22898.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 22898.66, "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": 41492.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 32195.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33432.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26928.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24272.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 22898.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22898.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 26654.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36637.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26654.04, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27478.39, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27203.61, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 22898.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26654.04, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "ATARAX - 00093506001", "drug_information": { "unit": 10, "type": "ME" }, "code_information": [ { "code": "00093506001", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ASSAY IGA/IGD/IGG/IGM EA LC", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.43, "discounted_cash": 9, "minimum": 1.38, "maximum": 130.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "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": 9.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "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 Medi-Cal IPA", "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": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASPIRATE/INJECT GANGLION CYST", "code_information": [ { "code": "20612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 822, "discounted_cash": 392, "minimum": 54.36, "maximum": 822, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 57.08 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.17 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 507.18, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.36, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 491.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11074, "minimum": 8550, "maximum": 20076.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16033.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11296.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12891.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13599.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11185.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12625.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14397.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20067.59, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15571.21, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16169.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13024, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11739.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 12891.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17719.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12891.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13289.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13156.9, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12891.1, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20076.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11074.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16529.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12625.31, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATARAX - 00093506101", "drug_information": { "unit": 25, "type": "ME" }, "code_information": [ { "code": "00093506101", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ASSAY MERCURY LC", "code_information": [ { "code": "83825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.25, "discounted_cash": 16, "minimum": 4.875, "maximum": 16.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "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": 16.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "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": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "127.78% 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": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.25, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "APRESOLINE - 00904644061", "drug_information": { "unit": 10, "type": "ME" }, "code_information": [ { "code": "00904644061", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ATHERECTOMY AORTIC PERC", "code_information": [ { "code": "0236T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 14775, "minimum": 4132, "maximum": 35791.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "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": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19074.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15661.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19269.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF PSA TOTAL LC - 84153 - 4100067", "code_information": [ { "code": "84153", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.89, "discounted_cash": 18, "minimum": 1, "maximum": 268.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "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": 4.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY ALKALINE PHOSPHATE LC", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 5, "minimum": 1, "maximum": 105.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "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": 2.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.5, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "Arsenic, Blood", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 94.85, "discounted_cash": 18, "minimum": 11.55, "maximum": 94.85, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.87 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 28.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.67 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.49, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.74, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY BRACHIOCEPHA PERC", "code_information": [ { "code": "0237T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35761.4, "discounted_cash": 14775, "minimum": 4132, "maximum": 35791.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "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": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19074.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15661.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19269.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY SALICYLATE LC", "code_information": [ { "code": "80179", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.93, "discounted_cash": 18, "minimum": 1, "maximum": 310.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "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": 2.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY IGA/IGD/IGG/IGM EA", "code_information": [ { "code": "82784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.02, "discounted_cash": 9, "minimum": 1.38, "maximum": 130.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.08 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.01, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.13, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.88, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.64, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ART/VEN PENILE", "code_information": [ { "code": "93980", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1056.6, "discounted_cash": 133, "minimum": 133.8, "maximum": 1056.6, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 177.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 172.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 141.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 174.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 249.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "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": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "AUD COMPR AUTOMETRY EVAL SPCH", "code_information": [ { "code": "0212T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408.96, "discounted_cash": 164, "minimum": 122.688, "maximum": 408.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 167.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 230.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 212.6, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 174.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 214.77, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 210.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 164.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 216.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 206.09, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY SERUM ALBUMIN", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.02, "discounted_cash": 4, "minimum": 3.429, "maximum": 94.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "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": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF IGE", "code_information": [ { "code": "82785", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.65, "discounted_cash": 16, "minimum": 2.595, "maximum": 106.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "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": 8.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ARTERIAL BLOOD GAS", "code_information": [ { "code": "82803", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 764.3, "discounted_cash": 26, "minimum": 13.6, "maximum": 764.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 27.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 39.11, "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": 26.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 36.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUD SPCH AUDIOMETRY THRSHLD", "code_information": [ { "code": "0210T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASTHMA - SOI : 3", "code_information": [ { "code": "1413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6672.27, "maximum": 7139.33, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7139.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASSAY OF PROTEIN URINE", "code_information": [ { "code": "84156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.35, "discounted_cash": 3, "minimum": 1, "maximum": 167.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 5.51, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.59, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.79, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.59, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUGMENTIN 500-125MG TAB", "drug_information": { "unit": 1, "type": "EA" }, "code_information": [ { "code": "00093227434", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ATHERECTOMY ILIAC PERC W/S&I", "code_information": [ { "code": "0238T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48061.2, "discounted_cash": 23462, "minimum": 4132, "maximum": 48061.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23931.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 35193.02, "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": 23696.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29362.31, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 32846.81, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 32987.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34254.53, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30289.53, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24869.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30598.61, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29362.31, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF PSA FREE", "code_information": [ { "code": "84154", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.88, "discounted_cash": 18, "minimum": 1.464, "maximum": 4.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "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": 4.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 2", "code_information": [ { "code": "0082", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 34562.44, "maximum": 36981.81, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36981.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6615, "minimum": 6217.86, "maximum": 11987.4491, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9593.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6747.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7700.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7997.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6681.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7541.77, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8600.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6615.59, "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": 11987.45, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9301.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9658.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7779.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7012.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7700.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10584.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7700.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7938.71, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7859.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7700.55, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6217.86 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6615.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9889.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7541.77, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF SERUM ALBUMIN LC", "code_information": [ { "code": "82040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.43, "discounted_cash": 4, "minimum": 3.429, "maximum": 94.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "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": 5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF CSF PROTEIN", "code_information": [ { "code": "83873", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.02, "discounted_cash": 17, "minimum": 4.806, "maximum": 16.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "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": 16.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.02, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45694.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATIVAN - 51079041720", "drug_information": { "unit": 0.5, "type": "ME" }, "code_information": [ { "code": "51079041720", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "ASSAY PHENOBARBITAL", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.25, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "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": 6.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "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 Medi-Cal IPA", "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": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.25, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY OF PSA TOTAL LC - G0103 - 4100067", "code_information": [ { "code": "G0103", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.89, "discounted_cash": 19, "minimum": 1.467, "maximum": 268.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "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": 4.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.89, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUTOMATED PLATELET COUNT LC - 85049 - 410619", "code_information": [ { "code": "85049", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.21, "discounted_cash": 4, "minimum": 1.458, "maximum": 140.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.72, "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": 4.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.61, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.3 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.54 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.84, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.61, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASSAY RBC PROTOPORHYRIN LC", "code_information": [ { "code": "84202", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.01, "discounted_cash": 14, "minimum": 2.103, "maximum": 14.02, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "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": 7.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ASSAY PHENOBARBITAL LC", "code_information": [ { "code": "80184", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.93, "discounted_cash": 15, "minimum": 1, "maximum": 439.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "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": 2.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.93, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "B pertussis IgG/IgM Ab", "code_information": [ { "code": "86615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.48, "discounted_cash": 13, "minimum": 9.444, "maximum": 31.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.47 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.79, "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": 13.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.51, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.2, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.85, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.51, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUGMENTIN 875-125MG TAB", "drug_information": { "unit": 875, "type": "ME" }, "code_information": [ { "code": "00093227534", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "AST/PLATELETS W/ APRI LC", "code_information": [ { "code": "84450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.21, "discounted_cash": 5, "minimum": 1.455, "maximum": 109, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.21, "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": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.21 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.69, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.76, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ASTHMA - SOI : 1", "code_information": [ { "code": "1411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3243.91, "maximum": 3470.98, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3470.98, "additional_payer_notes": "107% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19165, "minimum": 14400, "maximum": 34728.3571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28133.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 19549.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22308.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19165.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23762.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 19357.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21848.97, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24915.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19165.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19165.76, "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": 34728.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 26947.06, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27982.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22538.93, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20315.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19165.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19165.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 22308.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30665.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22308.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22998.91, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22768.92, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22308.94, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26596 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19165.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29003.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21848.97, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31216.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 2", "code_information": [ { "code": "1412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4806.49, "maximum": 5142.94, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5142.94, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 4", "code_information": [ { "code": "1414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11195.72, "maximum": 11979.42, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11979.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14377, "minimum": 9000, "maximum": 26051.8488, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20447.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 14664.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16735.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 17747.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 14521.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16390.24, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 18690.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 14377.4, "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": 26051.85, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 20214.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20991, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16907.82, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15240.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 16735.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23003.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16735.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17252.88, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17080.35, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16735.29, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20836.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14377.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21079.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16390.24, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 51625, "minimum": 51625, "maximum": 93544.5362, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86114.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 52657.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60091.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 51625.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 64535.72 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 52141.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58852.52, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 67112.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 51625.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 51625.02, "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": 93544.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 72584.78, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 75372.53, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60711.02, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54722.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 51625.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 51625.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 60091.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 82600.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60091.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61950.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61330.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60091.52, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 51625.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79958.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51625, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88777.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58852.52, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY AORTIC OPEN", "code_information": [ { "code": "0236T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 14775, "minimum": 4132, "maximum": 35791.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "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": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19074.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15661.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19269.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY BRACHIOCEPHA OPEN", "code_information": [ { "code": "0237T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 14775, "minimum": 4132, "maximum": 35791.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "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": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19074.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15661.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19269.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACTRIM DS", "drug_information": { "unit": 1, "type": "EA" }, "code_information": [ { "code": "00904272561", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "AVUL NAIL PLATE,@ADDTL N.PLATE", "code_information": [ { "code": "11732", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 253, "minimum": 21.36, "maximum": 253, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.36 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 22.43 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.36 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 21.36 }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.36 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.36 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.36 } ] } ] }, { "description": "ATHERECTOMY ILIAC OPEN W/S&I", "code_information": [ { "code": "0238T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48061.2, "discounted_cash": 23462, "minimum": 4132, "maximum": 48061.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23931.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 35193.02, "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": 23696.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29362.31, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 32846.81, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 32987.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 34254.53, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30289.53, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 24869.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30598.61, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29980.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23462.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30907.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 29362.31, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11565, "minimum": 11565.67, "maximum": 20956.994, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16596.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11797.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13462.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11565.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14215.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11681.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13184.86, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15035.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11565.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11565.67, "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": 20956.99, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 16261.33, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16885.88, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13601.23, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12259.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11565.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11565.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13462.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18505.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13462.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13878.8, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13740.02, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13462.44, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15411 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11565.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17110.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13184.86, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BAMLANIVIMAB INFUSION/MONITOR", "code_information": [ { "code": "M0239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1548, "discounted_cash": 389, "minimum": 389.28, "maximum": 1548, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 497.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 397.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 497.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 583.92, "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": 393.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 487.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 544.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 547.33, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 568.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.56, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 412.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 497.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 497.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 507.69, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 497.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 389.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 512.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 487.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "B CELLS TOT CNT", "code_information": [ { "code": "86355", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.15, "discounted_cash": 37, "minimum": 15.345, "maximum": 51.15, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 35.21 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 51.15, "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": 38.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.22, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 51.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 51.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 51.15 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.71, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.21, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.21, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.7, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.22, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "ATHERECTOMY RENAL OPEN/PERC", "code_information": [ { "code": "0234T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35791.4, "discounted_cash": 14775, "minimum": 4132, "maximum": 35791.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.79, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15070.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 22162.5, "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": 14922.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20685, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20773.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21571.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19074.57, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15661.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19269.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18879.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14775, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19463.85, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18490.66, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BCR-ABL1 CML/ALL PCR QUANT LC", "code_information": [ { "code": "81206", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 163, "minimum": 15, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "B-TYP NATR PEPT - 83880 - 4153527", "code_information": [ { "code": "83880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 835.2, "discounted_cash": 39, "minimum": 24.12, "maximum": 835.2, "payers_information": [ { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.2, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 58.89, "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": 39.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 54.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 55.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.68, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.62, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "ATIVAN - 00904600861", "drug_information": { "unit": 1, "type": "ME" }, "code_information": [ { "code": "00904600861", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "Atypical Panca", "code_information": [ { "code": "86256", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.29, "discounted_cash": 12, "minimum": 1.788, "maximum": 83, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 7.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.29 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.29, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BCR/ABL1 TRANS ANLYS MINOR BP", "code_information": [ { "code": "81207", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 144, "minimum": 15, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR", "code_information": [ { "code": "518", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35594, "minimum": 24300, "maximum": 64497.1796, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51133.16 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 36306.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41431.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 35594.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 44399.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 35950.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40577.7, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 46272.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 35594.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 35594.47, "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": 64497.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 50045.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 51967.93, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41859.1, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37730.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 35594.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35594.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 41431.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56951.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41431.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42713.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42286.23, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41431.96, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39327.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 35594.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52714.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40577.7, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 56329, "minimum": 56329.2, "maximum": 102068.5104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86114.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 57455.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65567.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 70444.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 56892.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64215.29, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 73227.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 56329.2, "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": 102068.51, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 79198.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 82240.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66243.14, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 59708.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 65567.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 90126.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65567.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67595.04, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66919.09, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65567.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59945.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56329.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88777.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64215.29, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 1", "code_information": [ { "code": "7581", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3371.12, "maximum": 3607.1, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3607.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8895.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOMATED PLATELET COUNT LC - 85049 - 410617", "code_information": [ { "code": "85049", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.86, "discounted_cash": 4, "minimum": 1.458, "maximum": 140.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.96 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "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": 4.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.86, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 4", "code_information": [ { "code": "0494", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25716.97, "maximum": 27517.16, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27517.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUD PURE TONE AUDIOMETRY AUTO - 0208T - 6294001", "code_information": [ { "code": "0208T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "AUTOMATED RBC COUNT", "code_information": [ { "code": "85041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.67, "discounted_cash": 3, "minimum": 1.101, "maximum": 3.67, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "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": 3.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.27 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24641, "minimum": 24641.68, "maximum": 44650.7242, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34200.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25134.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30640.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24888.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28091.52, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 32034.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44650.72, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 34646.2, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 35976.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26120.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39426.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29570.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29274.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30398.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35258.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28091.52, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "AUD PURE TONE AUDIOMETRY AUTO - 0209T - 6294002", "code_information": [ { "code": "0209T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BERYLLIUM SERUM/PLASMA LC", "code_information": [ { "code": "83018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 69, "discounted_cash": 21, "minimum": 20.7, "maximum": 69, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.4, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 23.49 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 32.94, "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": 22.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 30.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 30.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 32.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.35, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 23.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.64, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 28.93, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACTROBAN 2% OINT", "drug_information": { "unit": 22, "type": "GR" }, "code_information": [ { "code": "45802011222", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "AUD SPEECH AUDIOMETRY AUTO REC", "code_information": [ { "code": "0211T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.25, "discounted_cash": 47, "minimum": 30.975, "maximum": 103.25, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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" } ] } ] }, { "description": "AVUL NAIL PLATE,PART/COMP,SGL", "code_information": [ { "code": "11730", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 882.25, "discounted_cash": 256, "minimum": 45.93, "maximum": 882.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 261.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 385.17, "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": 259.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 359.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 361.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 374.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 331.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 272.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 334.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BETA-2-MICROGLOBLN", "code_information": [ { "code": "82232", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 16, "minimum": 3.126, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.6 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 24.27, "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": 16.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 22.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 22.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.1, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.25, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24372.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69665.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11811.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BETA-2-GKYCOPROTEIN*LC", "code_information": [ { "code": "86146", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15, "discounted_cash": 25, "minimum": 1.5, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15, "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": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "127.78% 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": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "B-TYP NATR PEPT - 83880 - 4103527", "code_information": [ { "code": "83880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 237.15, "discounted_cash": 39, "minimum": 24.12, "maximum": 835.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 58.89, "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": 39.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.13, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 54.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 55.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.81 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.68, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.62, "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": 24.12, "10th_percentile": 24.12, "90th_percentile": 24.12, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.2, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 51.72, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.13, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BACTERIAL AG* FOCUS", "code_information": [ { "code": "87802", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83, "discounted_cash": 12, "minimum": 8.08, "maximum": 83, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.1, "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": 12.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 17.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 17.9 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.59 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.6, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "408", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33970, "minimum": 33750, "maximum": 69606.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49953.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34650.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39541.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 33970.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 42359.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 34310.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38726.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 44161.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33970.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 33970.61, "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": 61554.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 47762.68, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49597.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39949.44, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36008.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33970.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33970.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39541.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54352.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39541.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40764.73, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40357.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39541.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 69606.6 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33970.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51498.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38726.5, "additional_payer_notes": "114.00% of Medicare 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": 52482, "minimum": 31950, "maximum": 95098.8698, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87552.59 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 53532.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61090, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 52482.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 65613.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 53007.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59830.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 68227.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 52482.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 52482.82, "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": 95098.87, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 73790.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 76624.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61719.8, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55631.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 52482.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52482.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 61090, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83972.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61090, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62979.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62349.59, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61090, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 81294 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52482.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90260.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59830.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BACITRACIN ZINC OINT", "drug_information": { "unit": 15, "type": "GR" }, "code_information": [ { "code": "00472110534", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33533, "minimum": 33533.67, "maximum": 60763.01, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52056.21 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 34204.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39033.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 33533.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41810.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33869.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38228.38, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 43593.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 33533.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 33533.67, "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": 60763.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 47148.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 48959.16, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39435.6, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35545.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 33533.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33533.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 39033.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 53653.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39033.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40240.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39838, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39033.19, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39381.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33533.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53666.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38228.38, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BIPAP MGMT DLY", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1876.8, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "410", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15264, "minimum": 14850, "maximum": 27659.3102, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22129.68 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15569.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15264.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18861.88 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15417.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17401.55, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19843.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15264.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15264.52, "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": 27659.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 21461.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22286.2, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17951.08, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16180.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15264.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15264.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24423.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18317.42, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18134.25, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17767.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24739 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15264.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22814.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17401.55, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16711.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24641, "minimum": 23244.8, "maximum": 44650.7242, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35258.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28091.52, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34200.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25134.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 30640.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 24888.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28091.52, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 32034.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44650.72, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 34646.2, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 35976.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28978.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26120.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39426.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29570.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29274.32, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28682.92, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24641.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23244.8 } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4573.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BILIRUBN TOTAL - 82247 - 4102250", "code_information": [ { "code": "82247", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 101.1, "discounted_cash": 5, "minimum": 3.075, "maximum": 101.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "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": 5.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.55, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14612.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17829, "minimum": 14850, "maximum": 32306.8909, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25335.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18185.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20753.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 17829.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22083.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18007.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20325.53, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23178.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 17829.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 17829.41, "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": 32306.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 25068.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26030.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20967.39, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18899.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 17829.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17829.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 20753.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28527.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20753.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21395.29, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21181.34, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20753.43, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19987.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17829.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26119 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20325.53, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BCR/ABL1 TRANS ANLYS MAJOR BP", "code_information": [ { "code": "81206", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 163, "minimum": 15, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BCR-ABL1 GENE MINOR BP LC", "code_information": [ { "code": "81207", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 144, "minimum": 15, "maximum": 50, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 50, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BLD CRYOPRCPTAT$", "code_information": [ { "code": "P9012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30, "discounted_cash": 71, "minimum": 9, "maximum": 437.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 30, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 30, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BIS LIMB FLUID DIFF", "code_information": [ { "code": "93702", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 152.75, "discounted_cash": 164, "minimum": 45.825, "maximum": 152.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 110.39 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "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": 152.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 105.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 152.75, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19876, "minimum": 4600, "maximum": 36015.3482, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25630.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20273.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23135.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 19876.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 24654.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20074.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22658.66, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 25838.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 19876.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 19876.02, "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": 36015.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 27945.68, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29018.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23374.2, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21068.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 19876.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19876.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23135.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31801.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23135.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23851.22, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23612.71, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23135.69, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19876.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14652 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19876, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26423.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22658.66, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BLD TYP AG SCR", "code_information": [ { "code": "86904", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 211.5, "discounted_cash": 75, "minimum": 7.182, "maximum": 211.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 77.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.18 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 97.47, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 98.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.49, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BK VIRUS, QUANTITATIVE PCR", "code_information": [ { "code": "87799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 65, "discounted_cash": 42, "minimum": 19.5, "maximum": 75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.61, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 59.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 60.23 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.31, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.87, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.61, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4466.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BLD TYP AG TSTG RGNT SERUM - 86902 - 7219698", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83.65, "discounted_cash": 458, "minimum": 2.62, "maximum": 105.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "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": 83.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 83.65, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLADDER IRRIGATION SMPL LAVAGE", "code_information": [ { "code": "51700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1216.05, "discounted_cash": 319, "minimum": 112.69, "maximum": 1216.05, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 326.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 118.32 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 479.66, "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": 322.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 400.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 447.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 449.6, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 466.86, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 412.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 338.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 421.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 417.04, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 408.61, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 112.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 319.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 421.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 400.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BENTYL - 00591079401", "drug_information": { "unit": 10, "type": "ME" }, "code_information": [ { "code": "00591079401", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7268.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BLD TYPE ABO - 86900 - 4106080", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 161.5, "discounted_cash": 170, "minimum": 2.541, "maximum": 161.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "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": 161.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "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": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "127.78% 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": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 161.5, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD PLSMA FROZN$", "code_information": [ { "code": "P9059", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 166.95, "discounted_cash": 73, "minimum": 18, "maximum": 166.95, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 74.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 81.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 110.12, "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": 74.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.87, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 102.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 103.21, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 107.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 83.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 94.77, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 77.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 95.74, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 93.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 77.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 73.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.71, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 91.87, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BETA 2 GLYCOPROTEIN I AB EA LC", "code_information": [ { "code": "86146", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132, "discounted_cash": 25, "minimum": 1.5, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.49 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 38.18, "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": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 35.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.86, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BENADRYL INJ", "drug_information": { "unit": 1, "type": "ML" }, "code_information": [ { "code": "00641037625", "type": "NDC" }, { "code": "J1200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.4, "median_amount": 13.18, "10th_percentile": 13.18, "90th_percentile": 13.18, "count": "1 through 10" } ] } ] }, { "description": "BLD UREA NTRG Q - 84520 - 4104520", "code_information": [ { "code": "84520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 222.6, "discounted_cash": 3, "minimum": 3.61, "maximum": 222.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.94, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.55 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.1, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.94, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD RC LEUK PR $", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1500, "discounted_cash": 184, "minimum": 184, "maximum": 1500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 235.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 187.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 235.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 194.41 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 276, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 185.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 230.27, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 257.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 258.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 268.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 198.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 237.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 195.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 235.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 235.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 239.97, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 235.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 184, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 242.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 230.27, "additional_payer_notes": "125.15% of Medicare 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": 25405, "minimum": 9900, "maximum": 46035.4002, "payers_information": [ { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28962.67, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40857.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 25913.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29572.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 25405.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 31600.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 25659.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28962.67, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 33027.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 25405.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 25405.85, "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": 46035.4, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 35720.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 37092.54, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29877.28, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26930.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 25405.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25405.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 29572.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40649.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29572.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30487.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30182.15, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29572.41, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28359.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25405.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42121.6 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11316, "minimum": 11316, "maximum": 20504.592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18013.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11542.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13171.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 13901.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11429.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12900.24, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 14710.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20504.59, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 15910.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16521.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13307.62, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11994.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13171.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18105.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13171.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13579.2, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13443.41, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13171.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16726.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11316, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18570.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12900.24, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BLEED TIME TMPL - 85002 - 4105003", "code_information": [ { "code": "85002", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 261.2, "discounted_cash": 4, "minimum": 4.6, "maximum": 261.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.87 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.22, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "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": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.29, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% 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": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD TYP AG TSTG RGNT SERUM - 86902 - 7257714", "code_information": [ { "code": "86902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.73, "discounted_cash": 458, "minimum": 2.62, "maximum": 105.65, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": 16.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.73, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BILIRUBN DIRECT", "code_information": [ { "code": "82248", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 102.2, "discounted_cash": 5, "minimum": 5.02, "maximum": 102.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "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": 5.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.55, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7077, "minimum": 4649.67, "maximum": 12823.7414, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10620.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7218.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8577.36 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7147.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8067.92, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9200.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7077.12, "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": 12823.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9950.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10332.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8322.69, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7501.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11323.39, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8492.54, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8407.62, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8237.77, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4649.67 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7077.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10948.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8067.92, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BLEED TIME TMPL - 85002 - 4155003", "code_information": [ { "code": "85002", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 185.8, "discounted_cash": 4, "minimum": 4.6, "maximum": 261.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.87 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.22, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "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": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.29, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "127.78% 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": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD TYP RH PHEN", "code_information": [ { "code": "86906", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26, "discounted_cash": 47, "minimum": 5.98, "maximum": 75.75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.36 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 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": 26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "140.60% 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, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "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": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26, "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": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "127.78% 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": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BILIRUBN TOTAL - 82247 - 4152250", "code_information": [ { "code": "82247", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 5, "minimum": 3.075, "maximum": 101.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "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": 5.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.55, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BENTYL - 51079011920", "drug_information": { "unit": 20, "type": "ME" }, "code_information": [ { "code": "51079011920", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "BLOOD GAS PH PO2 &/OR PCO2", "code_information": [ { "code": "82803", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.35, "discounted_cash": 26, "minimum": 13.6, "maximum": 764.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 27.42 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 39.11, "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": 26.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 36.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 36.65 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.66, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.34, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.63, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLOOD CULTURE ROUTINE LABCORP", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.75, "discounted_cash": 10, "minimum": 2.925, "maximum": 139, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "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": 9.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BODY FLUID CULT GS LC", "code_information": [ { "code": "87205", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.19, "discounted_cash": 4, "minimum": 1.779, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "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": 4.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.34, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.23 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.51, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.57, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.34, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLOOD TRANSFUSION ADMNSTRATION - 36430 - 4506024", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1940.2, "discounted_cash": 564, "minimum": 564.64, "maximum": 1940.2, "payers_information": [ { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 728.95, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 598.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 743.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 736.39, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 743.83, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 706.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 575.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 721.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "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 Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 706.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 790.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced 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 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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 564.64, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23506, "minimum": 23400, "maximum": 42594.2854, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33364.9 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 23976.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27361.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 23506.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 29215.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 23741.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26797.73, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 30558.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 23506.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 23506.78, "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": 42594.29, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 33050.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34319.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27643.97, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24917.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 23506.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23506.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 27361.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37610.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27361.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28208.14, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27926.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27361.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23787.8 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23506.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34396.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26797.73, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BENZODIAZEPINES 1-12 LC", "code_information": [ { "code": "G0482", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.94, "discounted_cash": 198, "minimum": 1, "maximum": 993.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "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": 2.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.94 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.94, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12508, "minimum": 12508.59, "maximum": 22665.5651, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18632.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 12758.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14560, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 12508.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 15400.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 12633.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14259.79, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 16261.17, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 12508.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 12508.59, "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": 22665.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 17587.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18262.54, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14710.1, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13259.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 12508.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12508.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 14560, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20013.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14560, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15010.31, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14860.2, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14560, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17301.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12508.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19209 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14259.79, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BIPAP PER DAY", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 471.85, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" } ] } ] }, { "description": "BETA-HYDROXYBUTYRATE", "code_information": [ { "code": "82010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.65, "discounted_cash": 8, "minimum": 8.17, "maximum": 136.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.13 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.26, "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": 8.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.22, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.77 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.55, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.66, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.22, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8099, "minimum": 6637.95, "maximum": 14676.2578, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11907.33 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 8261.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9427.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 9861.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8180.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9233.41, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 10529.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8099.48, "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": 14676.26, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 11387.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11825.24, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9524.99, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8585.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 9427.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12959.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9427.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9719.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9622.18, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9427.79, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6637.95 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8099.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12275.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9233.41, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BONE IMG 3PHASE", "code_information": [ { "code": "78315", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1478.5, "discounted_cash": 511, "minimum": 163.6, "maximum": 1478.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 521.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 197.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 767.48, "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": 516.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 716.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 719.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 747.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 660.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 542.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 667.28, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 163.6 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7828.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3384.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BONE IMG LTD", "code_information": [ { "code": "78300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1289.5, "discounted_cash": 511, "minimum": 97.49, "maximum": 1289.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 521.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 121.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 767.48, "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": 516.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 716.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 719.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 747.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.31 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 660.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 542.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 667.28, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BK VIRUS (BKV)QUANT PCR URINE", "code_information": [ { "code": "87799", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75, "discounted_cash": 42, "minimum": 19.5, "maximum": 75, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.61, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 59.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 60.23 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.76 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.31, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 43.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 55.87, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 54.74, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 42.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 56.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.61, "additional_payer_notes": "125.15% of Medicare 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": 20840, "minimum": 20700, "maximum": 37763.3303, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29910.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 21257.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24258.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20840.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25866.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 21049.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23758.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 27092.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20840.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20840.69, "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": 37763.33, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 29302.01, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30427.41, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24508.65, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22091.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20840.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20840.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 24258.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33345.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24258.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25008.83, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24758.74, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24258.56, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32334.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20840.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30836 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23758.39, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11759.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BONE IMG WH/BDY", "code_information": [ { "code": "78306", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1869.2, "discounted_cash": 511, "minimum": 171.95, "maximum": 1869.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 521.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 212.4 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 767.48, "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": 516.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 716.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 719.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 747.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 183.99 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 660.54, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 542.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 667.28, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 653.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 171.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 511.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 674.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 640.32, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD PHER LEUKO", "code_information": [ { "code": "P9035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1143.94, "discounted_cash": 509, "minimum": 228.6, "maximum": 1143.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 650.51, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 519.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 650.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 524.51 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 763.62, "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": 514.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 637.1, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 712.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 715.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 743.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 534.5 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 657.22, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 539.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 650.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 650.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 663.93, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 650.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 499.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 509.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 670.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 637.1, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BILIRUBIN, TOTAL BF LC827969", "code_information": [ { "code": "82247", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.25, "discounted_cash": 5, "minimum": 3.075, "maximum": 101.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "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": 5.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.06 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.55, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 2", "code_information": [ { "code": "1322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4672.92, "maximum": 5000.02, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5000.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "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": "BLD RC PACKED $", "code_information": [ { "code": "P9021", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1500, "discounted_cash": 149, "minimum": 129.66, "maximum": 1500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 152.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 136.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 224.75, "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": 151.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.51, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 209.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 210.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 138.74 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 193.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 158.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 197.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 195.4, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 191.46, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 149.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 197.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 187.51, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32920, "minimum": 32920.8, "maximum": 59652.5258, "payers_information": [ { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 32920.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 41040.65 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 33250.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37529.73, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 42797.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 32920.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 32920.82, "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": 59652.53, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 46286.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 48064.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38714.88, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34896.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 32920.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32920.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 38319.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 52673.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38319.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39504.98, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39109.93, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38319.83, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53311.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50581.9 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37529.73, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49064.44 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 33579.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32920.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38319.83, "additional_payer_notes": "116.40% of Medicare Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4859.5, "maximum": 5199.66, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5199.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7196.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BLD TYPE ABO - 86900 - 4156080", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 89.14, "discounted_cash": 170, "minimum": 2.541, "maximum": 161.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "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": 89.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "146.00% 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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "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": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "127.78% 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": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 89.14, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BIPAP < 12HRS", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 938.4, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11205.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6585, "minimum": 5642.61, "maximum": 11932.618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9938.43 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6717.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7665.32, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7959.6 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6651.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7507.28, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8560.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6585.33, "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": 11932.62, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 9258.97, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9614.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7744.35, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6980.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7665.32, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10536.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7665.32, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7902.4, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7823.37, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7665.32, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5642.61 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6585.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10245.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7507.28, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BODY FLUID CULT AER/ANA/GS LC", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.19, "discounted_cash": 8, "minimum": 1.596, "maximum": 467.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "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": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.22 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% 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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BIPAP INIT", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 559.14, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRCA1 TARGETED ANAL LC", "code_information": [ { "code": "81215", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 300, "discounted_cash": 375, "minimum": 74.41, "maximum": 300, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 78.13 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 74.41 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 300, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRUCELLA AB LC", "code_information": [ { "code": "86622", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 56.93, "discounted_cash": 8, "minimum": 3.786, "maximum": 56.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.15 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.4, "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": 9.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.18, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.56 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.04 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.53, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.65, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.11 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.18, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BODY FLUID CULT ANA LC", "code_information": [ { "code": "87075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.19, "discounted_cash": 9, "minimum": 3.057, "maximum": 278.81, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "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": 9.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.19 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.19, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "Bipap/Cpap Initial", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 540, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20494, "minimum": 15300, "maximum": 38164.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29210.39 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 20904.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23855.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 25431.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 20699.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23363.79, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 26642.92, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37136.12, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 28815.34, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29922.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24101.59, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21724.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 23855.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32791.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23855.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24593.46, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24347.53, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23855.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38164.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20494.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30113.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23363.79, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BSC METABLC PNL", "code_information": [ { "code": "80048", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 932.9, "discounted_cash": 8, "minimum": 8.34, "maximum": 932.9, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.59, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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": 464.4, "10th_percentile": 10.57, "90th_percentile": 475.79, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.89 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.92, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA 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": 7.27, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.03, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.59, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.34 } ] } ] }, { "description": "Bipap/Cpap/Partial", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 471.85, "discounted_cash": 280, "minimum": 58.52, "maximum": 1876.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 61.45 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 62.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 361.82, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 365.51, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.52 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 350.74, "additional_payer_notes": "125.15% of Medicare 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": 18493, "minimum": 9900, "maximum": 36099.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28321.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18863.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21526.24, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18493.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22917.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18678.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21082.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24041.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18493.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18493.33, "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": 33509.91, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 26001.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27000.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21748.16, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19602.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18493.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18493.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21526.24, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29589.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21526.24, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22192, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21970.08, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21526.24, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36099.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18493.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29197.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21082.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BSS PLUS", "drug_information": { "unit": 500, "type": "ML" }, "code_information": [ { "code": "00065080050", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8075.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3644.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24358.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99001.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRCAssure COMP PANEL LC485030", "code_information": [ { "code": "81162", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1500, "discounted_cash": 1824, "minimum": 450, "maximum": 1500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD SMR EXM *", "code_information": [ { "code": "85008", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.05, "discounted_cash": 3, "minimum": 1, "maximum": 24.05, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.34 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 4.82 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.43, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.47, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 1", "code_information": [ { "code": "1381", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2414.91, "maximum": 2583.95, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2583.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "C DIFF TOXIN ASSAY*SOH", "code_information": [ { "code": "87230", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 218, "discounted_cash": 19, "minimum": 19.74, "maximum": 218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 28.64 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 29.61, "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": 19.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.7, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 27.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.82 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.74, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.7, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD TYPE RHO D - 86901 - 4106100", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 177.4, "discounted_cash": 47, "minimum": 2.52, "maximum": 177.44, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 2", "code_information": [ { "code": "1382", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3832.26, "maximum": 4100.52, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4100.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "C E A - 82378 - 4106151", "code_information": [ { "code": "82378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 349.6, "discounted_cash": 18, "minimum": 2.247, "maximum": 349.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.29 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 28.44, "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": 19.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.73, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLD TYPE RHO D - 86901 - 4156100", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 177.44, "discounted_cash": 47, "minimum": 2.52, "maximum": 177.44, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.7, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34529.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BLD UREA NTRG Q - 84520 - 4154520", "code_information": [ { "code": "84520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154.35, "discounted_cash": 3, "minimum": 3.61, "maximum": 222.6, "payers_information": [ { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.15, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.2, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.94, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4.94, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 5.55 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.86 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 3.61 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.1, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.61 } ] } ] }, { "description": "C DIFF TOXIN RFLEX TO AB AG LC", "code_information": [ { "code": "87493", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 125, "discounted_cash": 37, "minimum": 22.91, "maximum": 250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 30.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 55.91, "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": 37.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 52.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 52.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.12, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.61, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.64, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9433, "minimum": 8730.07, "maximum": 17094.2993, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13791.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9622.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10981.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 11537.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 9528.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10754.69, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 12264.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 9433.94, "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": 17094.3, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 13264.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13773.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11094.31, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9999.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10981.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15094.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10981.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11320.73, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11207.52, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10981.11, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8730.07 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9433.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14218.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10754.69, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "BLOOD CULTURE ROUTINE LC", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.75, "discounted_cash": 10, "minimum": 2.925, "maximum": 139, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "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": 9.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "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": 127.51, "10th_percentile": 127.51, "90th_percentile": 127.51, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.75, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "C E A - 82378 - 4156151", "code_information": [ { "code": "82378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 239.93, "discounted_cash": 18, "minimum": 2.247, "maximum": 349.6, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.98, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.29 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.34 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 28.44, "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": 19.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 23.73, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 26.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 26.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 27.68 } ] } ] }, { "description": "CA 27-29", "code_information": [ { "code": "86300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.58, "discounted_cash": 20, "minimum": 2.574, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "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": 8.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BURN DRESS/DEBRID,P THICK(SML)", "code_information": [ { "code": "16020", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 882.25, "discounted_cash": 256, "minimum": 45.4, "maximum": 882.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 261.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 385.17, "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": 259.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 359.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 361.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 374.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 331.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 272.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 334.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLOOD CULTURE*SOH", "code_information": [ { "code": "87040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 139, "discounted_cash": 10, "minimum": 2.925, "maximum": 139, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.32 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 14.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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", "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": 127.51, "10th_percentile": 127.51, "90th_percentile": 127.51, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 14.51 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.32, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.3 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.46, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.19, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.6, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.92, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "C. DIFFICILE (ILLUMIGENE)", "code_information": [ { "code": "87493", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 250, "discounted_cash": 37, "minimum": 22.91, "maximum": 250, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 30.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 55.91, "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": 37.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 52.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 52.4 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 54.41 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.12, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 48.61, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 47.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 37.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.1, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 46.64, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CA-125", "code_information": [ { "code": "86304", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.33, "discounted_cash": 20, "minimum": 2.499, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "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": 8.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.33 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.33, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BURN,DRESS/DEBRID (LARGE)", "code_information": [ { "code": "16030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 847, "discounted_cash": 520, "minimum": 116.95, "maximum": 847, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.82, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 530.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 122.8 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 780.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 525.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 651.12, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 728.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 731.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 759.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 125.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 671.68, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 551.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 678.54, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 664.83, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 520.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 685.39, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 651.12, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLOOD GAS PUNCTURE", "code_information": [ { "code": "36600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 575.8, "discounted_cash": 170, "minimum": 18.16, "maximum": 756.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.07 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 219.83, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 222.08, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 213.1, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BURN,DRESS/DEBRID (MEDIUM)", "code_information": [ { "code": "16025", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 847, "discounted_cash": 256, "minimum": 86.51, "maximum": 847, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 261.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 90.84 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 385.17, "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": 259.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 359.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 361.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 374.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.57 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 331.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 272.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 334.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 86.51 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BLOOD HEMOGLOBN", "code_information": [ { "code": "85018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 85.3, "discounted_cash": 2, "minimum": 2.37, "maximum": 85.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2.77 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 3.56, "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": 2.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.97, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 3.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 3.33 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.55 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.06, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.09, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3.12, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2.97, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CALC URINE QUAN", "code_information": [ { "code": "82340", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 203.5, "discounted_cash": 6, "minimum": 6.03, "maximum": 203.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.55, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.86, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.55, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 2", "code_information": [ { "code": "8422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16502.58, "maximum": 17657.76, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17657.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BLOOD TRANSFUSION ADMNSTRATION - P9010 - 4506024", "code_information": [ { "code": "P9010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1940.2, "discounted_cash": 188, "minimum": 188.91, "maximum": 1940.2, "payers_information": [ { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 275.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 272.69 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 243.88, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 200.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 241.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 241.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 248.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 246.37, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 241.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 248.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 236.42, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 241.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 192.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 241.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 267.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.85 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 283.37, "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": 190.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 236.42, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 264.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 188.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 265.61, "additional_payer_notes": "140.60% of Medicare Rates" } ] } ] }, { "description": "CALCIUM - 82310 - 4102310", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.3, "discounted_cash": 5, "minimum": 1, "maximum": 126.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.25 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.66, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BODY FLUID CULTURE*SOH", "code_information": [ { "code": "87070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121, "discounted_cash": 8, "minimum": 1.596, "maximum": 467.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.83 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.93, "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": 8.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.12 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.59 }, { "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 Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.13, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.24, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.01, "additional_payer_notes": "127.78% 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": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CALCIUM ION", "code_information": [ { "code": "82330", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.89, "discounted_cash": 13, "minimum": 2.367, "maximum": 27.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "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": 7.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.89, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BONE MARROW SMEAR", "code_information": [ { "code": "85097", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 234.8, "discounted_cash": 1031, "minimum": 53.088, "maximum": 234.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 53.09 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "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": 234.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 234.8, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CALCULI, URINARY", "code_information": [ { "code": "82360", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.14, "discounted_cash": 12, "minimum": 3.309, "maximum": 13.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "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": 13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "Calculi, with Photograph", "code_information": [ { "code": "82365", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.05, "discounted_cash": 12, "minimum": 3.315, "maximum": 11.05, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "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": 11.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "Canalith Re-positioning", "code_information": [ { "code": "95992", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 139.4, "discounted_cash": 31, "minimum": 31.36, "maximum": 139.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 47.04, "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": 31.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 39.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 43.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 44.09 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 45.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.49, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 33.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.9, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 31.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 41.31, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 39.25, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CAMPYLOBACTER ANTIGEN CHARGE", "code_information": [ { "code": "86625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 13, "minimum": 13.12, "maximum": 52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.68, "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": 13.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.42, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 18.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 18.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "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": 14.32 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.42, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19256, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CA 19-9* LC", "code_information": [ { "code": "86301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.62, "discounted_cash": 20, "minimum": 3.126, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.87, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "BRCA1/2 FULL SEQ ANALYSIS LC", "code_information": [ { "code": "81162", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1500, "discounted_cash": 1824, "minimum": 450, "maximum": 1500, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1500, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7984.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CALCIUM - 82310 - 4152310", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.17, "discounted_cash": 5, "minimum": 1, "maximum": 126.3, "payers_information": [ { "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.25 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.66, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% 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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.73, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.46, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 7.74, "additional_payer_notes": "150.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10133.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARBAMAZAPINE", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 254.4, "discounted_cash": 14, "minimum": 2.13, "maximum": 290.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 3", "code_information": [ { "code": "1913", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12200.69, "maximum": 13054.74, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13054.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17739.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARBAMAZEPINE", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 290.93, "discounted_cash": 14, "minimum": 2.13, "maximum": 290.93, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16458.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29055.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARBON DIOXIDE", "code_information": [ { "code": "82374", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50, "discounted_cash": 4, "minimum": 1.56, "maximum": 50, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 6.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.67 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.3, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.36, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% 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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57056, "minimum": 27900, "maximum": 103386.3599, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 88375.83 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 58197.63, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66413.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 57056.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 71358.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 57627.07, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65044.4, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 74173.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 57056.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 57056.49, "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": 103386.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 80221.42, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83302.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67098.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60479.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 57056.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57056.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 66413.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91290.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66413.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68467.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67783.11, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66413.75, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 44963.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57056.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91109.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65044.4, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARBON MONOXIDE, BLOOD", "code_information": [ { "code": "82375", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.48, "discounted_cash": 12, "minimum": 3.444, "maximum": 11.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "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": 11.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.48, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14079.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARD STRESS THA", "code_information": [ { "code": "93017", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2317.5, "discounted_cash": 276, "minimum": 60.858, "maximum": 2317.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 281.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 60.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 345.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 386.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 356.77, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 292.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 360.41, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 345.85, "additional_payer_notes": "125.15% 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": 31012, "minimum": 25650, "maximum": 70512.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48596.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 31632.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36098.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 31012.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 38643.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 31322.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35354.01, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 40315.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 31012.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 31012.29, "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": 56194.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 43603.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45277.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36470.45, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32873.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 31012.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31012.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 36098.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49619.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36098.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37214.75, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36842.6, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36098.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70512.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31012.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50099.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35354.01, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15123.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BSS", "drug_information": { "unit": 15, "type": "ML" }, "code_information": [ { "code": "00065079515", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3863.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16321.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 4552, "minimum": 4552.9, "maximum": 8249.8548, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6301.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 4643.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5299.58, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 5406.59 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 4598.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5190.31, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 5918.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 4552.9, "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": 8249.85, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 6401.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 6647.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5354.21, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 4826.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 5299.58, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7284.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5299.58, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5463.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5408.85, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5299.58, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5851.47 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4552.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6496.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 5190.31, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14162.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "217", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 62435, "minimum": 23400, "maximum": 113132.22, "payers_information": [ { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 94984.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71175.9, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 92135.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 63683.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72674.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 78114.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 63059.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71175.9, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 81165.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 113132.22, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 87783.61, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 91155.1, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73423.56, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66181.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 72674.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 99896, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72674.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74922, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74172.78, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 72674.34, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 62435, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62681 } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURN, INITIAL TX/DRESSING", "code_information": [ { "code": "16000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 882.25, "discounted_cash": 256, "minimum": 45.93, "maximum": 882.25, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 261.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 385.17, "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": 259.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 359.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 361.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 374.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.15 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 331.5, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 272.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 334.89, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 328.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 256.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 338.27, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 321.36, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9884.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "216", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 92770, "minimum": 48150, "maximum": 168099.4031, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 137692.76 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 94625.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107984.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 92770.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 116219.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 93697.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105757.9, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 120601.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 92770.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 92770.09, "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": 168099.4, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 130434.75, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 135444.33, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 109097.63, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 98336.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 92770.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 92770.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 107984.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 148432.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107984.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111324.11, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110210.87, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107984.38, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 136977 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 92770.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 141951.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105757.9, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 3", "code_information": [ { "code": "2013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7540.49, "maximum": 8068.32, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8068.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11033.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15151, "minimum": 15151.98, "maximum": 27455.3878, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21363.47 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15455.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17636.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15151.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18720.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15303.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17273.26, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19697.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15151.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15151.98, "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": 27455.39, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 21303.68, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22121.89, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17818.73, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16061.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15151.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15151.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17636.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24243.17, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17636.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18182.38, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18000.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17636.9, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15151.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19836.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15152, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22024.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17273.26, "additional_payer_notes": "114.00% of Medicare 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": 50683, "minimum": 25200, "maximum": 91839.3899, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 51190.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57779.75, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 65889.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 50683.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 50683.99, "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": 91839.39, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 71261.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 73998.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59604.37, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 53725.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 50683.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 50683.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 58996.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 81094.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58996.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60820.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60212.58, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58996.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 50683.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62554.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77905.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57779.75, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 75568.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 51697.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 58996.16, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 50683.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 50684, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 63353.66 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7206, "minimum": 6336.01, "maximum": 13058.5223, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10547.59 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 7350.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8388.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 8740.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 7278.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8215.63, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 9368.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 7206.69, "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": 13058.52, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 10132.61, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10521.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8475.07, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7639.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 8388.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11530.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8388.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8648.03, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8561.55, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8388.59, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6336.01 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7206.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10873.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8215.63, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 43928, "minimum": 14850, "maximum": 79598.3695, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66368.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 44807.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51132.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 43928.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 54867.78 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 44367.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50078.44, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 57107, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 43928.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 43928.46, "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": 79598.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 61763.41, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64135.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51659.87, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46564.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 43928.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 43928.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 51132.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 70285.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51132.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52714.15, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52187.01, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51132.73, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 63940.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 43928.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68421.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50078.44, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "219", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 72866, "minimum": 38250, "maximum": 132034.4242, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110391.34 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 74324.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84816.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 91218.2 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 73595.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83068.02, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 94726.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 132034.42, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 102450.55, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 106385.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85691.22, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 77238.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 84816.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 116586.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84816.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87440.02, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86565.62, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84816.82, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 90784.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 72866.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 113805.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83068.02, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11635, "minimum": 11446.4, "maximum": 21083.8159, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17204.6 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 11868.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13543.91, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 11635.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 14303.52 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 11752.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13264.65, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 15126.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 11635.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 11635.66, "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": 21083.82, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 16359.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16988.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13683.54, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12333.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 11635.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11635.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 13543.91, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18617.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13543.91, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13962.79, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13823.16, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13543.91, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11446.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11635.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17736.7 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13264.65, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CA-125* LC", "code_information": [ { "code": "86304", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.62, "discounted_cash": 20, "minimum": 2.499, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.87, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15663.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47375.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8354.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CA15-3", "code_information": [ { "code": "86300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.02, "discounted_cash": 20, "minimum": 2.574, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "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": 12.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.02 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18128, "minimum": 13500, "maximum": 33107.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27073.19 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18490.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21101.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18128.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 22459.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18309.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20666.23, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 23566.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18128.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18128.27, "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": 32848.43, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 25488.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26467.27, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21318.85, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19216, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18128.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18128.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21101.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29005.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21101.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21753.92, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21536.38, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21101.31, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33107.4 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18128.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27910.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20666.23, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51935.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9088.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CA15-3* LC", "code_information": [ { "code": "86300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.62, "discounted_cash": 20, "minimum": 2.574, "maximum": 41.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.43 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.87, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.14, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.8 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15663, "minimum": 9000, "maximum": 28382.4976, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21654.57 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15976.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18232.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 19363.21 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15820.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17856.54, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 20362.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28382.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 22023.06, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22868.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18420.43, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16603.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 18232.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25061.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18232.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18796.36, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18608.39, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18232.47, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20107.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15663.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22324.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17856.54, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 4", "code_information": [ { "code": "2054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15093.7, "maximum": 16150.26, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16150.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27049.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CALPROTECTIN,FECAL", "code_information": [ { "code": "83993", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55, "discounted_cash": 19, "minimum": 13.96, "maximum": 55, "payers_information": [ { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.57, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.32 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.57, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 27.6 }, { "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.34, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.6, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% 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" } ] } ] }, { "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": 47916, "minimum": 13950, "maximum": 86825.0785, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65522.92 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 48875.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55775.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 59877.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 48395.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54625.05, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 62291.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 86825.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 67370.89, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 69958.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56350.05, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50791.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 55775.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 76666.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55775.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57500.05, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 56925.05, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55775.05, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52074.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 47916.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67549.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54625.05, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIOVERSION/DEFIBRILLATION", "code_information": [ { "code": "92960", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3100.5, "discounted_cash": 845, "minimum": 175.66, "maximum": 3100.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 862.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 184.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 1268.87, "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": 854.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1058.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1184.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1189.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1235.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 187.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1092.07, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 896.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1114.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1103.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1114.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1058.64, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30389.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CALR MUTATION ANALSYS LC489450", "code_information": [ { "code": "81338", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 175, "discounted_cash": 150, "minimum": 52.5, "maximum": 300, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 153.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 126.27 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "fee schedule", "standard_charge_dollar": 151.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 175 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 175 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 128.68 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 159.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 120.26 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 150.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 175, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1623", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 57853.9, "maximum": 61903.67, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61903.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIZEM SR", "drug_information": { "unit": 60, "type": "ME" }, "code_information": [ { "code": "51079092420", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29965, "minimum": 21600, "maximum": 54297.1961, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40026.18 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 30564.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34879.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 29965.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 37328.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 30264.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34160.49, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 38954.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 29965.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 29965.34, "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": 54297.2, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 42131.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 43749.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35239.24, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31763.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 29965.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29965.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 34879.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 47944.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34879.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35958.41, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35598.82, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34879.66, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37165.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 29965.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41264.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34160.49, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1624", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 80771.14, "maximum": 86425.12, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86425.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36856, "minimum": 21150, "maximum": 66783.2713, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55480.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 37593.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42900.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 36856.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 45983.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 37224.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42015.97, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 47912.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 36856.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 36856.11, "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": 66783.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 51819.69, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 53809.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43342.79, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39067.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 36856.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36856.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 42900.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58969.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42900.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44227.33, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43785.06, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42900.51, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51515.1 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36856.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57196.2 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42015.97, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4137.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34173.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CATECHOLAMINES FREE URINE*LC1", "code_information": [ { "code": "82384", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.75, "discounted_cash": 25, "minimum": 5.925, "maximum": 31.39, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "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": 19.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.75, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIOLIPIN AB EA IG LC", "code_information": [ { "code": "86147", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132, "discounted_cash": 25, "minimum": 3.243, "maximum": 132, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 31.14 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 38.18, "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": 25.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 35.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 35.78 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 37.16 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "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": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.86, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.19, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 32.52, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 33.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 31.85, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARD STRESS TRC", "code_information": [ { "code": "93017", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2013, "discounted_cash": 276, "minimum": 60.858, "maximum": 2317.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 281.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 60.86 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 345.85, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 386.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 80.58 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 356.77, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 292.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 360.41, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 353.13, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.31 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 276.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 364.05, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 345.85, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36891.48, "maximum": 39473.88, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39473.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 2", "code_information": [ { "code": "2052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5360.93, "maximum": 5736.2, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5736.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6244, "minimum": 5850, "maximum": 11315.6863, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10049.69 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 6369.76, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7269.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 7531.92 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 6307.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7119.14, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 8118.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 6244.86, "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": 11315.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 8780.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9117.5, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7343.96, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6619.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 7269.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9991.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7269.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7493.83, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7418.89, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7269.02, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9331.56 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6244.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10360.5 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7119.14, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIOVERSION-ICU", "code_information": [ { "code": "92960", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3100.5, "discounted_cash": 845, "minimum": 175.66, "maximum": 3100.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 862.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 184.44 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 1268.87, "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": 854.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1058.64, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 1184.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 1189.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1235.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 187.96 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1092.07, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 896.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1114.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1103.22, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1080.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 175.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 845.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1114.36, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1058.64, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CATH IV PLCMNT", "code_information": [ { "code": "Z7610", "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": 52.69, "10th_percentile": 52.69, "90th_percentile": 52.69, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15020, "minimum": 9000, "maximum": 27513.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23375.16 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17483.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 15020.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 18555.37 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 15170.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17123.39, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 19526.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 15020.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 15020.52, "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": 27217.18, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 21118.85, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21929.96, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17664.13, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15921.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 15020.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15020.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 17483.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24032.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17483.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18024.62, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17844.38, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17483.89, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27513.7 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24098.1 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17123.39, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CATECHOLAMINES FRAC PLASMA LC", "code_information": [ { "code": "82384", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.25, "discounted_cash": 25, "minimum": 5.925, "maximum": 31.39, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "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": 25.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services 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 Cal-Mediconnect", "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 Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "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 Medi-Cal IPA", "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": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% 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": 25.25 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 25.25 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.25, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CATH LEFT HEART W/VENTRCLGRPH", "code_information": [ { "code": "93452", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15281.8, "discounted_cash": 4149, "minimum": 549.26, "maximum": 15281.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5301.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4232.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 801 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5192.69, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5808.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 587.71 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5356.67, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4398.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5411.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 549.26 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5192.69, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIZEM", "drug_information": { "unit": 30, "type": "ME" }, "code_information": [ { "code": "63739007910", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4061.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CATHETER NASAL EPISTAT", "code_information": [ { "code": "Z7610", "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": 52.69, "10th_percentile": 52.69, "90th_percentile": 52.69, "count": "1 through 10" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5602, "minimum": 5382.45, "maximum": 10152.0743, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7982.42 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 5714.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6521.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 6725.27 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 5658.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6387.07, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 7283.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 5602.69, "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": 10152.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 7877.38, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8179.93, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6588.76, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5938.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 6521.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 8964.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6521.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6723.23, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6656, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6521.53, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5382.45 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5602.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8229.3 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6387.07, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CATH RIGHT HEART", "code_information": [ { "code": "93451", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15281.8, "discounted_cash": 4149, "minimum": 579.86, "maximum": 15281.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5301.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4232.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 733.56 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "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": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5192.69, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 5808.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "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 Enhanced 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 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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 620.45 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "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": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5356.67, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4398.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "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": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5411.33, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5302.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.86 }, { "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": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4149.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5465.99, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5192.69, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18622, "minimum": 5400, "maximum": 33744.6948, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26152.95 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 18995.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21677.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 23080.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 18809.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21230.11, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 24209.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 18622.9, "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": 33744.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 26183.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27189.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21900.53, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19740.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 21677.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29796.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21677.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22347.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22124.01, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21677.06, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26860.9 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18622.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26961.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21230.11, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 4", "code_information": [ { "code": "1914", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18727.73, "maximum": 20038.67, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20038.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CBC/DIFF&PLATLT - 85025 - 4105028", "code_information": [ { "code": "85025", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 310.5, "discounted_cash": 7, "minimum": 7.75, "maximum": 310.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.62 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 11.66, "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": 7.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 10.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "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": 154.57, "10th_percentile": 9.73, "90th_percentile": 158.36, "count": "1 through 10" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 10.92 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.34 }, { "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 Medi-Cal IPA", "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": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.03, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "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": 5.4, "10th_percentile": 5.4, "90th_percentile": 6.75, "count": "1 through 10" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "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": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.13, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.93, "additional_payer_notes": "127.78% 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": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CATAPRES - 00228212810", "drug_information": { "unit": 0.2, "type": "ME" }, "code_information": [ { "code": "00228212810", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11551.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4006.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELL CT SYNOVIAL FLUID LC", "code_information": [ { "code": "89051", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.5, "discounted_cash": 5, "minimum": 1.39, "maximum": 217.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.99 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 8.4, "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": 5.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 7.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 7.87 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.18 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.49 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.38, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "125.15% of Medicare Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8885, "minimum": 8885.4, "maximum": 16100.3448, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13217.03 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 9063.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10342.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 10848.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 8974.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10129.36, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 11551.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 8885.4, "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": 16100.34, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 12492.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12972.68, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10449.23, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9418.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 10342.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14216.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10342.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10662.48, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10555.86, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10342.61, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10577.5 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8885.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13625.8 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10129.36, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 3", "code_information": [ { "code": "3833", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7731.31, "maximum": 8272.5, "payers_information": [ { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8272.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13690, "minimum": 13690.79, "maximum": 24807.7115, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20961.12 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 13964.62, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15936.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 13690.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 16885.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 13827.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15607.5, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 17798.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 13690.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 13690.79, "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": 24807.71, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 19249.25, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19988.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16100.37, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14512.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 13690.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13690.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 15936.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21905.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15936.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16428.95, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16264.66, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15936.08, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15147.2 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13690.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21609.4 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15607.5, "additional_payer_notes": "114.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 67684, "minimum": 37350, "maximum": 122645.0026, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100825.29 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 69038.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78785.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 67684.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 84709.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 68361.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77160.76, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 87990.34, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 67684.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 67684.88, "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": 122645, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 95164.94, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 98819.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 79597.42, "additional_payer_notes": "117.60% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "case rate", "standard_charge_dollar": 71745.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "case rate", "standard_charge_dollar": 67684.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 67684.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "case rate", "standard_charge_dollar": 78785.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 108295.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78785.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81221.86, "additional_payer_notes": "120.00% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80409.64, "additional_payer_notes": "118.80% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 78785.2, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77717.3 }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "case rate", "standard_charge_dollar": 67684.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 103943.6 }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77160.76, "additional_payer_notes": "114.00% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15335.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CERV W FLEX/EXT", "code_information": [ { "code": "72052", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 960.5, "discounted_cash": 133, "minimum": 49.79, "maximum": 960.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation MSSP", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 80.67 }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "fee schedule", "standard_charge_dollar": 200.7, "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": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "fee schedule", "standard_charge_dollar": 188.12, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 195.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.28 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "HEALTHSMART PREFERRED CARE NETWORK", "plan_name": "Healthsmart Preferred Network Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 172.74, "additional_payer_notes": "129.10% of Medicare Rates" }, { "payer_name": "Imperial Health Plan CA", "plan_name": "Imperial Health Plan CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 141.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Covered CA and Covered Direct", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Duals", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "Managed Health Network", "plan_name": "Managed Health Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN, INC. (dba CLARITEV) Worker Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PRIME HEALTH SERVICES, INC.", "plan_name": "PRIME HEALTH SERVICES Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "PROVIDER NETWORK OF AMERICA", "plan_name": "PROVIDER NETWORK OF AMERICA Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "PROVIDER SELECT", "plan_name": "Provider Select Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 174.5, "additional_payer_notes": "130.42% of Medicare Rates" }, { "payer_name": "Renal Payer Solutions", "plan_name": "Renal Payer Solutions Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "THREE RIVERS", "plan_name": "THREE RIVERS PROVIDER NETWORK, INC Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 49.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "USA Senior Care Network", "plan_name": "USA Senior Care Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Workers Comp", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "ZELIS HEALTHCARE", "plan_name": "Zelis Healthcare (FKA) Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 167.45, "additional_payer_notes": "125.15% of Medicare 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": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10422.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medi-Cal IPA", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "LA Care Health Plan", "plan_name": "L.A Care Health Plan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CEPHULAC", "drug_information": { "unit": 30, "type": "ML" }, "code_information": [ { "code": "00121115440", "type": "NDC" }, { "code": "Z7610", "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": 2.14, "10th_percentile": 0.7, "90th_percentile": 21, "count": "1 through 10" } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45916, "minimum": 31950, "maximum": 83200.5893, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69299.32 }, { "payer_name": "AIDS Healthcare Foundation", "plan_name": "Aids Health Care Foundation Medicare", "methodology": "case rate", "standard_charge_dollar": 46834.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 45916.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "AMERICAS CHOICE PROVIDER NETWORK", "plan_name": "Americas Choice Provider Network Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53446.74, "additional_payer_notes": "116.40% of Medicare Rates" }, { "payer_name": "BLUE SHIELD OF CA, VA", "plan_name": "Blue Shield of CA, VA", "methodology": "case rate", "standard_charge_dollar": 45916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Sheild Of Promise Duals", "methodology": "case rate", "standard_charge_dollar": 45916.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange (01-01-2022 to 12-31-2026)", "methodology": "case rate", "standard_charge_dollar": 57364.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Medicare", "methodology": "case rate", "standard_charge_dollar": 46375.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "CORVEL", "plan_name": "Corvel Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52344.74, "additional_payer_notes": "114.00% of Medicare Rates" }, { "payer_name": "Employer Direct Healthcare", "plan_name": "Employer Direct Healthcare", "methodology": "case rate", "standard_charge_dollar": 59691.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Serivces (TRICARE)", "plan_name": "Health Net Federal Services Tricare", "methodology": "case rate", "standard_charge_dollar": 45916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Cal-Mediconnect", "methodology": "case rate", "standard_charge_dollar": 45916.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83200.59, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Enhanced PPO", "methodology": "case rate", "standard_charge_dollar": 64558.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 67038, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net of CA", "plan_name": "Health Net Of CA Medicare",